Basic Information
| Provider Information | |||||||||
| NPI: | 1720372402 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALLARD | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 OAKHURST DR | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253142049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043458101 | ||||||||
| FaxNumber: | 3043457386 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 OAKHURST DR | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253142049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043458101 | ||||||||
| FaxNumber: | 3043457386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2011 | ||||||||
| LastUpdateDate: | 05/31/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SLP0717 | WV | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.