Healthcare Provider Details

I. General information

NPI: 1811374135
Provider Name (Legal Business Name): HEIDI BALLATO EDS, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 JUNIPER BEND CIR
GREENVILLE SC
29615-6229
US

IV. Provider business mailing address

380 JUNIPER BEND CIR
GREENVILLE SC
29615-6229
US

V. Phone/Fax

Practice location:
  • Phone: 864-385-0407
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number206082
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: