Basic Information
| Provider Information | |||||||||
| NPI: | 1487173001 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALLARD | ||||||||
| FirstName: | LATISHA | ||||||||
| MiddleName: | DIANNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 E MAIN ST STE 117 | ||||||||
| Address2: | |||||||||
| City: | BARSTOW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923112365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602551496 | ||||||||
| FaxNumber: | 7602552542 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 E MAIN ST STE 117 | ||||||||
| Address2: | |||||||||
| City: | BARSTOW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923112365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602551496 | ||||||||
| FaxNumber: | 7602552542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2017 | ||||||||
| LastUpdateDate: | 06/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 3171 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | 92717 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.