Healthcare Provider Details

I. General information

NPI: 1114465564
Provider Name (Legal Business Name): DIANA BALLARD PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 04/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 TRAVIS AVE
STATEN ISLAND NY
10314-6154
US

IV. Provider business mailing address

510 TRAVIS AVE
STATEN ISLAND NY
10314-6154
US

V. Phone/Fax

Practice location:
  • Phone: 917-763-2476
  • Fax: 718-370-3534
Mailing address:
  • Phone: 917-763-2476
  • Fax: 718-370-3534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberBCCC#0557
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: