Provider Demographics
NPI:1114465564
Name:BALLARD, DIANA (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:BALLARD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 TRAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6154
Mailing Address - Country:US
Mailing Address - Phone:917-763-2476
Mailing Address - Fax:718-370-3534
Practice Address - Street 1:510 TRAVIS AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6154
Practice Address - Country:US
Practice Address - Phone:917-763-2476
Practice Address - Fax:718-370-3534
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-06
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYBCCC#0557101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral