Provider Demographics
NPI:1053299982
Name:MEDAK, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MEDAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19973 S 590 RD
Mailing Address - Street 2:
Mailing Address - City:WELLING
Mailing Address - State:OK
Mailing Address - Zip Code:74471-2411
Mailing Address - Country:US
Mailing Address - Phone:253-678-7098
Mailing Address - Fax:
Practice Address - Street 1:205 J T STITES BLVD
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-9323
Practice Address - Country:US
Practice Address - Phone:918-775-7787
Practice Address - Fax:918-775-0328
Is Sole Proprietor?:No
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor