Healthcare Provider Details

I. General information

NPI: 1487173001
Provider Name (Legal Business Name): LATISHA DIANNE BALLARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2017
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 E MAIN ST STE 117
BARSTOW CA
92311-2365
US

IV. Provider business mailing address

222 E MAIN ST STE 117
BARSTOW CA
92311-2365
US

V. Phone/Fax

Practice location:
  • Phone: 760-255-1496
  • Fax: 760-255-2542
Mailing address:
  • Phone: 760-255-1496
  • Fax: 760-255-2542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3171
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number92717
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: