Basic Information
| Provider Information | |||||||||
| NPI: | 1982900783 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALLARD | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7353 ELLENA W | ||||||||
| Address2: | UNIT 82 | ||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917308367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609468200 | ||||||||
| FaxNumber: | 7609468208 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 E GUASTI RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917618661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092484412 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2011 | ||||||||
| LastUpdateDate: | 08/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 75676 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.