Provider Demographics
NPI:1801365465
Name:BALLAST, JULIE SUZANNE (MSOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:SUZANNE
Last Name:BALLAST
Suffix:
Gender:F
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6142 SHALLOWFORD RD STE 104
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-7216
Mailing Address - Country:US
Mailing Address - Phone:423-463-0683
Mailing Address - Fax:
Practice Address - Street 1:6142 SHALLOWFORD RD STE 104
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-7216
Practice Address - Country:US
Practice Address - Phone:423-463-0683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
GAOT007423225X00000X
TN6056225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician