Provider Demographics
NPI:1326606724
Name:BALLOU, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BALLOU
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 1:412 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:MA
Mailing Address - Zip Code:01867-4004
Mailing Address - Country:US
Mailing Address - Phone:781-942-2345
Mailing Address - Fax:
Practice Address - Street 1:607 NORTH AVE
Practice Address - Street 2:DOOR 11
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880
Practice Address - Country:US
Practice Address - Phone:434-586-6926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA380103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst