Provider Demographics
NPI:1457738049
Name:BALLARD, ELIZABETH HALEY
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:HALEY
Last Name:BALLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 MURRAY ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-4672
Mailing Address - Country:US
Mailing Address - Phone:270-293-1309
Mailing Address - Fax:
Practice Address - Street 1:415 PACE ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-1246
Practice Address - Country:US
Practice Address - Phone:931-668-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-03
Last Update Date:2015-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2443224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2443OtherSTATE LICENSURE NUMBER