Provider Demographics
NPI:1609811512
Name:BALLARD, MARIJEAN DALE (ATC)
Entity Type:Individual
Prefix:
First Name:MARIJEAN
Middle Name:DALE
Last Name:BALLARD
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 SUMMERTIME PKWY
Mailing Address - Street 2:
Mailing Address - City:DEATSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36022-5371
Mailing Address - Country:US
Mailing Address - Phone:205-601-5160
Mailing Address - Fax:205-378-1920
Practice Address - Street 1:289 SUMMERTIME PKWY
Practice Address - Street 2:
Practice Address - City:DEATSVILLE
Practice Address - State:AL
Practice Address - Zip Code:36022-5371
Practice Address - Country:US
Practice Address - Phone:205-601-5160
Practice Address - Fax:205-378-1920
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer