Provider Demographics
NPI:1609959006
Name:BALLOU, ROGER ASHMAN (PHD, LMFT, LPC)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:ASHMAN
Last Name:BALLOU
Suffix:
Gender:M
Credentials:PHD, LMFT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 THOMAS AVE S
Mailing Address - Street 2:APARTMENT 1526
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4477
Mailing Address - Country:US
Mailing Address - Phone:651-246-7592
Mailing Address - Fax:
Practice Address - Street 1:2900 THOMAS AVE S
Practice Address - Street 2:APARTMENT 1526
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-4477
Practice Address - Country:US
Practice Address - Phone:651-246-7592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI723106H00000X
MN1130106H00000X
NH203106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist