Provider Demographics
NPI:1598075590
Name:BURCHARD-BALLARD, PEGGY LOUISE (MA)
Entity Type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:LOUISE
Last Name:BURCHARD-BALLARD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S 24TH ST
Mailing Address - Street 2:SIMON COTTAGE
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4446
Mailing Address - Country:US
Mailing Address - Phone:217-222-0034
Mailing Address - Fax:217-222-3865
Practice Address - Street 1:205 S 24TH ST
Practice Address - Street 2:SIMON COTTAGE
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4446
Practice Address - Country:US
Practice Address - Phone:217-222-0034
Practice Address - Fax:217-222-3865
Is Sole Proprietor?:No
Enumeration Date:2010-10-12
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.007358101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional