Provider Demographics
NPI:1710665302
Name:BALLOU, SARA MARIE
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:MARIE
Last Name:BALLOU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:FOXBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02035-2729
Mailing Address - Country:US
Mailing Address - Phone:508-838-4201
Mailing Address - Fax:
Practice Address - Street 1:76 SUMMER ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-0200
Practice Address - Country:US
Practice Address - Phone:508-838-4201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-23-66089103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst