Healthcare Provider Details

I. General information

NPI: 1689597114
Provider Name (Legal Business Name): ISABEL MARY BALLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2026
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5640 W MAPLE RD
WEST BLOOMFIELD MI
48322-3716
US

IV. Provider business mailing address

6970 PALOS VERDES LN
WATERFORD MI
48327-4089
US

V. Phone/Fax

Practice location:
  • Phone: 248-880-3204
  • Fax:
Mailing address:
  • Phone: 248-880-3204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201014704
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: