Provider Demographics
NPI:1972641637
Name:BALLARD, BEVERLY ANN (PHD CLINICAL PSYCH)
Entity Type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:ANN
Last Name:BALLARD
Suffix:
Gender:F
Credentials:PHD CLINICAL PSYCH
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 70245
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94807-0245
Mailing Address - Country:US
Mailing Address - Phone:510-232-7732
Mailing Address - Fax:
Practice Address - Street 1:2340 WARD ST
Practice Address - Street 2:105
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1124
Practice Address - Country:US
Practice Address - Phone:510-232-7732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 7435103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL7435Medicare ID - Type Unspecified