Provider Demographics
NPI:1083621726
Name:BALL, ROBERT JONATHAN (LCSW, EDD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JONATHAN
Last Name:BALL
Suffix:
Gender:M
Credentials:LCSW, EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5730 E LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CAZENOVIA
Mailing Address - State:NY
Mailing Address - Zip Code:13035-9324
Mailing Address - Country:US
Mailing Address - Phone:315-655-3671
Mailing Address - Fax:315-428-8304
Practice Address - Street 1:1212 JAMES ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2808
Practice Address - Country:US
Practice Address - Phone:315-428-8844
Practice Address - Fax:315-428-8304
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR034319-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01963024Medicaid
NY01963024Medicaid
NY14352Medicare UPIN