Provider Demographics
NPI:1093024549
Name:MARSHALL BALLARD, CATHERINE
Entity Type:Individual
Prefix:MRS
First Name:CATHERINE
Middle Name:
Last Name:MARSHALL BALLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4424 COMANCHE DR
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-7205
Mailing Address - Country:US
Mailing Address - Phone:307-399-9153
Mailing Address - Fax:
Practice Address - Street 1:4424 COMANCHE DR
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-7205
Practice Address - Country:US
Practice Address - Phone:307-399-9153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY251C00000X251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY251C00000XMedicaid