Provider Demographics
NPI:1609634450
Name:BALLARD, OLIVIA MAREE (HIS)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:MAREE
Last Name:BALLARD
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:MAREE
Other - Last Name:POTEET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2202 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-2408
Mailing Address - Country:US
Mailing Address - Phone:660-619-3333
Mailing Address - Fax:
Practice Address - Street 1:904 THOMPSON BLVD
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2241
Practice Address - Country:US
Practice Address - Phone:660-826-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023028717237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
16112054OtherCAQH ID