Healthcare Provider Details

I. General information

NPI: 1154735306
Provider Name (Legal Business Name): VINCENT BALLARD JR. LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2014
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 CORPORATE PL
BRANSON MO
65616-9136
US

IV. Provider business mailing address

1300 E BRADFORD PKWY
SPRINGFIELD MO
65804-4264
US

V. Phone/Fax

Practice location:
  • Phone: 417-761-5950
  • Fax:
Mailing address:
  • Phone: 417-761-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2019012170
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: