Basic Information
| Provider Information | |||||||||
| NPI: | 1508990888 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | GERALDINE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OTR | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2447 | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354032447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509329393 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 PAUL W BRYANT DR E | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354012009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053450192 | ||||||||
| FaxNumber: | 2053457341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | OT4686 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 225XH1200X | 3203 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | 512-02180 | 01 | AL | BCBS | OTHER | 206106 | 05 | AL | MEDICAID |