Provider Demographics
NPI:1669017067
Name:BALLARD, ALLYSSA JUNE (LMSW)
Entity Type:Individual
Prefix:
First Name:ALLYSSA
Middle Name:JUNE
Last Name:BALLARD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:LYZA
Other - Middle Name:JUNE
Other - Last Name:BALLARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:15611 CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-2392
Mailing Address - Country:US
Mailing Address - Phone:616-723-1231
Mailing Address - Fax:
Practice Address - Street 1:4370 CHICAGO DR SW # 515
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1694
Practice Address - Country:US
Practice Address - Phone:586-585-6551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011054971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical