Provider Demographics
NPI:1487100699
Name:ULLOM, AUDRA (MFT)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:ULLOM
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 INDIAN DR
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-5653
Mailing Address - Country:US
Mailing Address - Phone:785-821-2497
Mailing Address - Fax:
Practice Address - Street 1:1510 INDIAN DR
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-7013
Practice Address - Country:US
Practice Address - Phone:785-821-2497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist