Healthcare Provider Details

I. General information

NPI: 1134031719
Provider Name (Legal Business Name): MAXINE LLOYD BALL REV DR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2026
Last Update Date: 09/19/2026
Certification Date: 09/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3017 OAK GREEN CT APT D
ELLICOTT CITY MD
21043-3524
US

IV. Provider business mailing address

PO BOX 2621
ELLICOTT CITY MD
21041-2621
US

V. Phone/Fax

Practice location:
  • Phone: 410-431-1114
  • Fax:
Mailing address:
  • Phone: 410-431-1114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC12400
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberLC12400
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: