Provider Demographics
NPI:1265459200
Name:BALLOU, MARSHALL
Entity Type:Individual
Prefix:MR
First Name:MARSHALL
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:PO BOX 10886
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-0886
Mailing Address - Country:US
Mailing Address - Phone:808-433-2998
Mailing Address - Fax:
Practice Address - Street 1:1 JARRETT WHITE RD
Practice Address - Street 2:TRIPLER ARMY MEDICAL CENTER
Practice Address - City:TAMC
Practice Address - State:HI
Practice Address - Zip Code:96859-5001
Practice Address - Country:US
Practice Address - Phone:808-433-2998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101333104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker