Healthcare Provider Details

I. General information

NPI: 1891533238
Provider Name (Legal Business Name): AUDRA BALLARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 SOLANO AVE STE 206
BERKELEY CA
94707-2218
US

IV. Provider business mailing address

1917 KINROSS WAY
SAN JOSE CA
95122-2943
US

V. Phone/Fax

Practice location:
  • Phone: 800-624-6190
  • Fax:
Mailing address:
  • Phone: 214-797-7064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number94029383
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: