Healthcare Provider Details

I. General information

NPI: 1336990621
Provider Name (Legal Business Name): AISHA B BALLARD CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2024
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W 7 MILE RD
DETROIT MI
48203-1968
US

IV. Provider business mailing address

13901 E JEFFERSON AVE
DETROIT MI
48215-2720
US

V. Phone/Fax

Practice location:
  • Phone: 313-368-2600
  • Fax: 313-369-2600
Mailing address:
  • Phone: 313-821-2591
  • Fax: 313-822-0950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: