Provider Demographics
NPI:1518112721
Name:BALLARD, CARISSA RENEE (LMT,MMP)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:RENEE
Last Name:BALLARD
Suffix:
Gender:F
Credentials:LMT,MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 E HIGHWAY ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-5006
Mailing Address - Country:US
Mailing Address - Phone:830-997-5267
Mailing Address - Fax:
Practice Address - Street 1:109 E HIGHWAY ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-5006
Practice Address - Country:US
Practice Address - Phone:830-997-5267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT013997225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist