Healthcare Provider Details

I. General information

NPI: 1972398345
Provider Name (Legal Business Name): HERBERT WAYNE BALLARD III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 N GRAND TRAVERSE ST
FLINT MI
48503-2536
US

IV. Provider business mailing address

5099 W FARRAND RD
CLIO MI
48420-8215
US

V. Phone/Fax

Practice location:
  • Phone: 810-487-4676
  • Fax:
Mailing address:
  • Phone: 586-491-1057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: