Provider Demographics
NPI:1669569273
Name:BALLARD, MICHELLE ROSE (RPT)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:ROSE
Last Name:BALLARD
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:ROSE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPT
Mailing Address - Street 1:501 BURNS AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-3335
Mailing Address - Country:US
Mailing Address - Phone:863-679-3338
Mailing Address - Fax:888-871-0887
Practice Address - Street 1:501 BURNS AVE
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-3335
Practice Address - Country:US
Practice Address - Phone:863-679-3338
Practice Address - Fax:888-871-0887
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT22565225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT22565OtherPT LICENSE
FL14456101OtherCITRUS IND ID
FLPT22565OtherPT LICENSE
FL891302100Medicaid