MEDICARE: MRS. DIANA ELAINE BALLARD

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	1041C0700X	Clinical Social Worker	9490518-3501	UT

General Provider Information

NPI Number	:	1235531641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DIANA ELAINE BALLARD

Provider Business Mailing Address
First Line	:	1368 W GREEN HEDGE WAY
Second Line	:
City	:	WEST JORDAN
State	:	UT
Zip	:	84084-4140
Country	:	US
Telephone Number	:	801-833-1291
Fax Number	:

Provider Business Practice Location Address
First Line	:	9071 S 1300 W STE 210
Second Line	:
City	:	WEST JORDAN
State	:	UT
Zip	:	84088-6725
Country	:	US
Telephone Number	:	801-833-1291
Fax Number	:

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

Provider Enumeration Date	:	09/17/2014
Last Update Date	:	12/27/2022

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