Provider Demographics
NPI:1114649902
Name:BALLARD, MADELINE GRACE
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:GRACE
Last Name: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 1:1433 BOWMAN RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-6539
Mailing Address - Country:US
Mailing Address - Phone:770-231-7757
Mailing Address - Fax:
Practice Address - Street 1:1433 BOWMAN RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-6539
Practice Address - Country:US
Practice Address - Phone:770-231-7757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician