Provider Demographics
NPI:1841994100
Name:BALLARD, SHUNDARRIUS LAMON
Entity type:Individual
Prefix:
First Name:SHUNDARRIUS
Middle Name:LAMON
Last Name:BALLARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 STUBBS AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5631
Mailing Address - Country:US
Mailing Address - Phone:318-582-5633
Mailing Address - Fax:318-562-5646
Practice Address - Street 1:626 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4619
Practice Address - Country:US
Practice Address - Phone:318-239-2325
Practice Address - Fax:318-239-2327
Is Sole Proprietor?:No
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator