Provider Demographics
NPI:1851546667
Name:BALLARD, AMANDA L (SAC-IT, OT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:BALLARD
Suffix:
Gender:F
Credentials:SAC-IT, OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 HUMES RD STE 100
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-0491
Mailing Address - Country:US
Mailing Address - Phone:608-741-2117
Mailing Address - Fax:
Practice Address - Street 1:2600 HUMES RD STE 100
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545
Practice Address - Country:US
Practice Address - Phone:608-741-2117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-20
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103657225X00000X
WI5202-26225X00000X
IL056008907225X00000X
WI18847-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN670000595Medicare PIN