Provider Demographics
NPI:1235801614
Name:BALLOU-BROADNAX, TRACI R (PSYD)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:R
Last Name:BALLOU-BROADNAX
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 1:312 NEFF AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801-3429
Mailing Address - Country:US
Mailing Address - Phone:540-433-2858
Mailing Address - Fax:540-433-1175
Practice Address - Street 1:312 NEFF AVE
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801-3429
Practice Address - Country:US
Practice Address - Phone:540-433-2858
Practice Address - Fax:540-433-1175
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810007624103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical