Provider Demographics
NPI:1982822169
Name:BALLARD, MICHAEL R (PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:BALLARD
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16587 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-7902
Mailing Address - Country:US
Mailing Address - Phone:269-273-2024
Mailing Address - Fax:269-273-3191
Practice Address - Street 1:16587 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-7902
Practice Address - Country:US
Practice Address - Phone:269-273-2024
Practice Address - Fax:269-273-3191
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010838103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist