Provider Demographics
NPI:1396625133
Name:BALLARD, KATHLEEN LAUREN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LAUREN
Last Name:BALLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:LAUREN
Other - Last Name:ANDERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2301 VILLAGE GREEN DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75044-7149
Mailing Address - Country:US
Mailing Address - Phone:925-202-7339
Mailing Address - Fax:
Practice Address - Street 1:2301 VILLAGE GREEN DR
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75044-7149
Practice Address - Country:US
Practice Address - Phone:925-202-7339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT124792225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist