Provider Demographics
NPI:1013286624
Name:BALLAGH, DOUGLAS WAYNE (LCSW)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:WAYNE
Last Name:BALLAGH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 LAGUNA NEGRA LN
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-9653
Mailing Address - Country:US
Mailing Address - Phone:805-343-0225
Mailing Address - Fax:
Practice Address - Street 1:HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93409-0001
Practice Address - Country:US
Practice Address - Phone:805-547-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS165761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical