Healthcare Provider Details

I. General information

NPI: 1952047748
Provider Name (Legal Business Name): TEDRA SHANISE BALLARD MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2022
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 OLD GREAT NECK RD STE 203
VIRGINIA BEACH VA
23454-3358
US

IV. Provider business mailing address

509 OLD GREAT NECK RD STE 203
VIRGINIA BEACH VA
23454-3358
US

V. Phone/Fax

Practice location:
  • Phone: 757-520-1312
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0906012260
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: