Provider Demographics
NPI:1083167944
Name:BALLARD-BOOTH, MONICA (MA, LSW)
Entity Type:Individual
Prefix:MS
First Name:MONICA
Middle Name:
Last Name:BALLARD-BOOTH
Suffix:
Gender:F
Credentials:MA, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 STATE ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MADISON
Mailing Address - State:WV
Mailing Address - Zip Code:25130-1367
Mailing Address - Country:US
Mailing Address - Phone:304-369-5283
Mailing Address - Fax:304-369-4800
Practice Address - Street 1:331 STATE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:MADISON
Practice Address - State:WV
Practice Address - Zip Code:25130-1367
Practice Address - Country:US
Practice Address - Phone:304-369-5283
Practice Address - Fax:304-369-4800
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1135103TC0700X
WVAP00941739104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker