MEDICARE: KAY R BALLARD LPC, LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	569	OK
2	106H00000X	Marriage & Family Therapist	1010	OK

General Provider Information

NPI Number	:	1063455863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAY R BALLARD LPC, LMFT

Provider Business Mailing Address
First Line	:	PO BOX 12883
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73157-2883
Country	:	US
Telephone Number	:	405-858-0600
Fax Number	:	405-858-0602

Provider Business Practice Location Address
First Line	:	2212 NW 50TH ST
Second Line	:	SUITE 172
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-8086
Country	:	US
Telephone Number	:	405-640-8121
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	01/30/2009

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