Provider Demographics
NPI:1972820199
Name:BALLARD, THEODORE J (DPT)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:J
Last Name:BALLARD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:WOMACK
Mailing Address - Street 2:2817 ROCK MERRITT AVE
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28307
Mailing Address - Country:US
Mailing Address - Phone:910-643-1472
Mailing Address - Fax:
Practice Address - Street 1:WOMACK
Practice Address - Street 2:2817 ROCK MERRITT AVE
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28307
Practice Address - Country:US
Practice Address - Phone:910-643-1472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-27
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC146412081S0010X
MD23236225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine