MEDICARE: AMY JEAN BALLOU OTD OTR

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	225X00000X	Occupational Therapist	01310	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	46281	OTHER	IA	WELLMARK

General Provider Information

NPI Number	:	1386712313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY JEAN BALLOU OTD OTR

Provider Business Mailing Address
First Line	:	2420 RIVER RIDGE DR
Second Line	:
City	:	WEST DES MOINES
State	:	IA
Zip	:	50265-2045
Country	:	US
Telephone Number	:	515-327-8645
Fax Number	:

Provider Business Practice Location Address
First Line	:	1978 GRAND AVE STE 45
Second Line	:
City	:	WEST DES MOINES
State	:	IA
Zip	:	50265-4217
Country	:	US
Telephone Number	:	515-221-2220
Fax Number	:

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

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	07/08/2007

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