Provider Demographics
NPI:1598954547
Name:BALLIN, BARBARA BROOKE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BARBARA
Middle Name:BROOKE
Last Name:BALLIN
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 1:463 AVALON VILLA DR
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-9423
Mailing Address - Country:US
Mailing Address - Phone:985-386-8368
Mailing Address - Fax:
Practice Address - Street 1:119 MULBERRY CIR
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-4962
Practice Address - Country:US
Practice Address - Phone:985-386-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA317103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1086681OtherWAIVER PROVIDER NUMBER