Provider Demographics
NPI:1679766737
Name:BALLARD, VANESSA RAE (PT)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:RAE
Last Name:BALLARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:RAE
Other - Last Name:KURTENBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7216 US HIGHWAY 301 N
Mailing Address - Street 2:SUITE 115
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-3462
Mailing Address - Country:US
Mailing Address - Phone:941-729-0003
Mailing Address - Fax:941-729-0004
Practice Address - Street 1:1727 2ND ST STE 2
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-8524
Practice Address - Country:US
Practice Address - Phone:941-951-0170
Practice Address - Fax:941-993-1088
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT13131225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT13131OtherSTATE LICENSE
FL892505400Medicaid