MEDICARE: VINCENT BALLARD JR. LPC

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	171M00000X	Case Manager/Care Coordinator
2	101YP2500X	Professional Counselor	2019012170	MO

General Provider Information

NPI Number	:	1154735306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VINCENT BALLARD JR. LPC

Provider Business Mailing Address
First Line	:	1300 E BRADFORD PKWY
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-4264
Country	:	US
Telephone Number	:	417-761-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	155 CORPORATE PL
Second Line	:
City	:	BRANSON
State	:	MO
Zip	:	65616-9136
Country	:	US
Telephone Number	:	417-761-5950
Fax Number	:

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

Provider Enumeration Date	:	06/16/2014
Last Update Date	:	07/26/2022

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