Basic Information
| Provider Information | |||||||||
| NPI: | 1174848253 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALLARD | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 765 | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446910765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303457949 | ||||||||
| FaxNumber: | 3303454218 | ||||||||
| Practice Location | |||||||||
| Address1: | 7317 PORTAGE ST NW | ||||||||
| Address2: | |||||||||
| City: | MASSILLON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446467827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309661620 | ||||||||
| FaxNumber: | 3309669348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2010 | ||||||||
| LastUpdateDate: | 04/01/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | E0500040 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.