Healthcare Provider Details

I. General information

NPI: 1336695733
Provider Name (Legal Business Name): TRACI DENISE BALLARD MA, MPA, LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 02/15/2020
Certification Date: 02/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 W ALEXANDRINE ST
DETROIT MI
48201-2015
US

IV. Provider business mailing address

79 W ALEXANDRINE ST
DETROIT MI
48201-2015
US

V. Phone/Fax

Practice location:
  • Phone: 313-831-5535
  • Fax: 313-831-2608
Mailing address:
  • Phone: 313-831-5535
  • Fax: 313-831-2608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401016840
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: