Provider Demographics
NPI:1861845596
Name:BALL, AMY (PT)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:
Last Name:BALL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 SHADOWBROOK RD
Mailing Address - Street 2:
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313-1727
Mailing Address - Country:US
Mailing Address - Phone:304-610-0465
Mailing Address - Fax:
Practice Address - Street 1:5320 SHADOWBROOK RD
Practice Address - Street 2:
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-1727
Practice Address - Country:US
Practice Address - Phone:304-610-0465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002165225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV002165OtherWEST VIRGINIA BOARD OF PHYSICAL THERAPY