Healthcare Provider Details

I. General information

NPI: 1679110324
Provider Name (Legal Business Name): MRS. ELIZABETH BALLARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2019
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 W 25TH ST FL 6
NEW YORK NY
10001-7474
US

IV. Provider business mailing address

356 S 1ST ST APT 23
BROOKLYN NY
11211-4717
US

V. Phone/Fax

Practice location:
  • Phone: 615-496-3812
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number088386
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: