Provider Demographics
NPI:1568809341
Name:BALLARD, BRANDI KAY (PTA)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:KAY
Last Name:BALLARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 FANNIN ST
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627-3434
Mailing Address - Country:US
Mailing Address - Phone:409-549-5243
Mailing Address - Fax:
Practice Address - Street 1:5957 9TH AVE
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-6204
Practice Address - Country:US
Practice Address - Phone:409-982-8878
Practice Address - Fax:409-982-5119
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4050873225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant