Provider Demographics
NPI:1437368446
Name:BALLA, ILDIKO (PHD)
Entity Type:Individual
Prefix:DR
First Name:ILDIKO
Middle Name:
Last Name:BALLA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2136 CLIFF PARK
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76134-1016
Mailing Address - Country:US
Mailing Address - Phone:682-597-3933
Mailing Address - Fax:817-274-8443
Practice Address - Street 1:4200 S HULEN ST STE 658
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4987
Practice Address - Country:US
Practice Address - Phone:682-597-3933
Practice Address - Fax:817-274-8443
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16553101YM0800X
TX32879103TC1900X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX028537102Medicaid