MEDICARE: BONNIE CHADWICK BALLANTINE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1916	OK

General Provider Information

NPI Number	:	1427165075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONNIE CHADWICK BALLANTINE LCSW

Provider Business Mailing Address
First Line	:	921 NE 13TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73104-5007
Country	:	US
Telephone Number	:	405-270-0501
Fax Number	:	405-270-1538

Provider Business Practice Location Address
First Line	:	1104 CHARLTON RD
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73003-6169
Country	:	US
Telephone Number	:	405-341-4496
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	07/08/2007

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