Provider Demographics
NPI:1568229987
Name:BALLARD, ANASTON CARLIE
Entity Type:Individual
Prefix:
First Name:ANASTON
Middle Name:CARLIE
Last Name:BALLARD
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 1:2041 OLD HIGHWAY 337
Mailing Address - Street 2:
Mailing Address - City:MENLO
Mailing Address - State:GA
Mailing Address - Zip Code:30731-6612
Mailing Address - Country:US
Mailing Address - Phone:706-844-3507
Mailing Address - Fax:
Practice Address - Street 1:2041 OLD HIGHWAY 337
Practice Address - Street 2:
Practice Address - City:MENLO
Practice Address - State:GA
Practice Address - Zip Code:30731-6612
Practice Address - Country:US
Practice Address - Phone:706-844-3507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-24-329307106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician