Provider Demographics
NPI:1033370663
Name:BALLARD, SUSANNE (BS, LLMSW)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:
Last Name:BALLARD
Suffix:
Gender:F
Credentials:BS, LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 MARSH RD
Mailing Address - Street 2:SUITE 27
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-2143
Mailing Address - Country:US
Mailing Address - Phone:517-327-6099
Mailing Address - Fax:517-327-6099
Practice Address - Street 1:4660 MARSH RD
Practice Address - Street 2:SUITE 27
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-2143
Practice Address - Country:US
Practice Address - Phone:517-327-6099
Practice Address - Fax:517-327-6099
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010853311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP208978490OtherBLUE CROSS AND BLUE SHEILD