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General NPI Number Information
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NPI Number | 1093135659
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Entity Type | Individual
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Provider Name | LUTISSUA D BALLARD PSYD
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Gender | Female
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Dates
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Enumeration Date | 04/22/2014
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Last Update Date | 08/04/2025
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Provider Practice Location Address
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Address Line | 210 W CONTINENTAL RD STE 229
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City | GREEN VALLEY
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State | AZ
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Zip | 85622-3596
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Country | US
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Telephone | 520-329-1579
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 204
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City | FORT MILL
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State | SC
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Zip | 29716-0204
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Country | US
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Telephone | 520-329-1579
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Fax |
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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 | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 4480
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 4480
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License Number State | AZ
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