Healthcare Provider Details

I. General information

NPI: 1154768158
Provider Name (Legal Business Name): MICHELLE BALL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2013
Last Update Date: 05/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 CALUMET AVE
VALPARAISO IN
46383-2614
US

IV. Provider business mailing address

148 WESTCHESTER LN
VALPARAISO IN
46385-8039
US

V. Phone/Fax

Practice location:
  • Phone: 219-462-0508
  • Fax:
Mailing address:
  • Phone: 219-531-7484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06004494A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: