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General NPI Number Information
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NPI Number | 1083167944
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Entity Type | Individual
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Provider Name | MONICA BALLARD-BOOTH MA, LSW
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Gender | Female
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Dates
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Enumeration Date | 07/27/2016
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Last Update Date | 07/27/2016
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Provider Practice Location Address
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Address Line | 331 STATE ST SUITE 300
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City | MADISON
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State | WV
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Zip | 25130-1367
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Country | US
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Telephone | 304-369-5283
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Fax | 304-369-4800
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Provider Business Mailing Address
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Address Line | 331 STATE ST SUITE 300
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City | MADISON
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State | WV
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Zip | 25130-1367
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Country | US
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Telephone | 304-369-5283
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Fax | 304-369-4800
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1135
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License Number State | WV
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | AP00941739
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License Number State | WV
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