Healthcare Provider Details

I. General information

NPI: 1407619737
Provider Name (Legal Business Name): CANDACE JEAN BALLSTADT LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2024
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 TOWN SQUARE LN
FARIBAULT MN
55021-6088
US

IV. Provider business mailing address

20325 410TH ST
GOODHUE MN
55027-7006
US

V. Phone/Fax

Practice location:
  • Phone: 507-323-8100
  • Fax:
Mailing address:
  • Phone: 651-380-9528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number20007
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: