Provider Demographics
NPI:1093135659
Name:BALLARD, LUTISSUA D (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LUTISSUA
Middle Name:D
Last Name:BALLARD
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 204
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29716-0204
Mailing Address - Country:US
Mailing Address - Phone:520-329-1579
Mailing Address - Fax:
Practice Address - Street 1:210 W CONTINENTAL RD STE 229
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85622-3596
Practice Address - Country:US
Practice Address - Phone:520-329-1579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4480103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ914097Medicaid
AZZ194557Medicaid