Basic Information
| Provider Information | |||||||||
| NPI: | 1013290394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALL | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4575 YATES RD | ||||||||
| Address2: | |||||||||
| City: | CROSS PLAINS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370494845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103600303 | ||||||||
| FaxNumber: | 2109220162 | ||||||||
| Practice Location | |||||||||
| Address1: | 4575 YATES RD # 101 | ||||||||
| Address2: | |||||||||
| City: | CROSS PLAINS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370494845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103600303 | ||||||||
| FaxNumber: | 2106155721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2011 | ||||||||
| LastUpdateDate: | 10/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 256005 | KY | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 6272 | TN | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 18056 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 06272 | 01 | TN | CLINICAL SOCIAL WORK LICENSE | OTHER | 285038002 | 05 | TX | MEDICAID |