Provider Demographics
NPI:1255192597
Name:BALLARD, ANGELA M (LMT)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:BALLARD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11294 SAN DOMINGO RD
Mailing Address - Street 2:
Mailing Address - City:MARDELA SPRINGS
Mailing Address - State:MD
Mailing Address - Zip Code:21837-2207
Mailing Address - Country:US
Mailing Address - Phone:410-726-5329
Mailing Address - Fax:
Practice Address - Street 1:9701 APOLLO DR STE 220
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-4783
Practice Address - Country:US
Practice Address - Phone:410-713-2194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM06216225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist