Provider Demographics
NPI:1003351412
Name:BALLARD, IVAN L (CDCA)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:L
Last Name:BALLARD
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:MR
Other - First Name:IVAN
Other - Middle Name:LEE
Other - Last Name:BALLARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CDCA
Mailing Address - Street 1:311 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-4535
Mailing Address - Country:US
Mailing Address - Phone:419-222-4474
Mailing Address - Fax:
Practice Address - Street 1:311 E MARKET ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4535
Practice Address - Country:US
Practice Address - Phone:419-222-4474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)