Provider Demographics
NPI:1942979158
Name:BALLOU, JUSTINE ELAINE (MS, CF-SLP)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:ELAINE
Last Name:BALLOU
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7915 JONES BRANCH DR APT 436
Mailing Address - Street 2:
Mailing Address - City:TYSONS CORNER
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3247
Mailing Address - Country:US
Mailing Address - Phone:401-617-6974
Mailing Address - Fax:
Practice Address - Street 1:8391 OLD COURTHOUSE RD STE 120
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3819
Practice Address - Country:US
Practice Address - Phone:703-429-1853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204000795235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty