Healthcare Provider Details

I. General information

NPI: 1669044053
Provider Name (Legal Business Name): JULIET IANNOLI-BALLARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2539 GWEN PL
OCEANO CA
93445-9160
US

IV. Provider business mailing address

2539 GWEN PL
OCEANO CA
93445-9160
US

V. Phone/Fax

Practice location:
  • Phone: 805-235-9269
  • Fax:
Mailing address:
  • Phone: 805-235-9269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: