Provider Demographics
NPI:1295391225
Name:BALLAST, ANTHONY TRAVON
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:TRAVON
Last Name:BALLAST
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 1:2214 PEBRICAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3852
Mailing Address - Country:US
Mailing Address - Phone:307-220-3201
Mailing Address - Fax:
Practice Address - Street 1:3120 OLD FAITHFUL RD STE 200
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5887
Practice Address - Country:US
Practice Address - Phone:307-221-2937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician