Healthcare Provider Details

I. General information

NPI: 1295105443
Provider Name (Legal Business Name): LORRI BALLARD LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 04/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 PEACOCK ALY
SANTA FE NM
87507-8601
US

IV. Provider business mailing address

19 PEACOCK ALY
SANTA FE NM
87507-8601
US

V. Phone/Fax

Practice location:
  • Phone: 505-927-9078
  • Fax:
Mailing address:
  • Phone: 505-927-9078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0188661
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: