Provider Demographics
NPI:1285657486
Name:BALLAS, ELISSA R
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:R
Last Name:BALLAS
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 1:101 BODIN CIR
Mailing Address - Street 2:
Mailing Address - City:TRAVIS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:94535-1809
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 BODIN CIR
Practice Address - Street 2:
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535
Practice Address - Country:US
Practice Address - Phone:707-423-7210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32918225100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist