MEDICARE: DORISHA DELORES BALLOU

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	172V00000X	Community Health Worker
2	175T00000X	Peer Specialist		CA

General Provider Information

NPI Number	:	1508666553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DORISHA DELORES BALLOU

Provider Business Mailing Address
First Line	:	655 MAPLE AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90014-2211
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	655 MAPLE AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90014-2211
Country	:	US
Telephone Number	:	310-848-9194
Fax Number	:

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

Provider Enumeration Date	:	03/18/2025
Last Update Date	:	06/01/2026

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Directions to “ DORISHA DELORES BALLOU ” Practice Location

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