Provider Demographics
NPI:1235425265
Name:BALLARD, JUSTINE MARIE (BCABA)
Entity Type:Individual
Prefix:MRS
First Name:JUSTINE
Middle Name:MARIE
Last Name:BALLARD
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:MISS
Other - First Name:JUSTINE
Other - Middle Name:MARIE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1051 E 560 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-2047
Mailing Address - Country:US
Mailing Address - Phone:719-930-5908
Mailing Address - Fax:
Practice Address - Street 1:7053 S 2310 W
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-3009
Practice Address - Country:US
Practice Address - Phone:801-255-5131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-11-4131103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst