Provider Demographics
NPI:1003478702
Name:BALLARD, AUTUMN (COTA/L)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:BALLARD
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:
Other - Last Name:BAUGUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:65 SHANNON LN
Mailing Address - Street 2:
Mailing Address - City:COUNCE
Mailing Address - State:TN
Mailing Address - Zip Code:38326-2044
Mailing Address - Country:US
Mailing Address - Phone:731-438-1140
Mailing Address - Fax:
Practice Address - Street 1:935 WAYNE RD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TN
Practice Address - Zip Code:38372-1904
Practice Address - Country:US
Practice Address - Phone:731-727-8010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant