Provider Demographics
NPI:1013925197
Name:BALLARD, DOUGLAS J (PT)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:J
Last Name:BALLARD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:D
Other - Middle Name:JAMES
Other - Last Name:BALLARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:520 WAKARA WAY
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1213
Mailing Address - Country:US
Mailing Address - Phone:801-587-9161
Mailing Address - Fax:801-587-7607
Practice Address - Street 1:520 WAKARA WAY
Practice Address - Street 2:SUITE 302
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1213
Practice Address - Country:US
Practice Address - Phone:801-587-9161
Practice Address - Fax:801-587-7607
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT274748-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist