Provider Demographics
NPI:1255689311
Name:BALLOU, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BALLOU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 SUNRISE BAY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-0540
Mailing Address - Country:US
Mailing Address - Phone:702-675-0201
Mailing Address - Fax:
Practice Address - Street 1:3020 SUNRISE BAY AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-0540
Practice Address - Country:US
Practice Address - Phone:702-675-0201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101Y00000XBehavioral Health & Social Service ProvidersCounselor