Provider Demographics
NPI:1942936695
Name:BALLARD, REBECCA (BA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BALLARD
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 768
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-0768
Mailing Address - Country:US
Mailing Address - Phone:815-844-6109
Mailing Address - Fax:815-844-3561
Practice Address - Street 1:920 W CUSTER AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-1067
Practice Address - Country:US
Practice Address - Phone:815-844-6109
Practice Address - Fax:815-844-3561
Is Sole Proprietor?:No
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)