Basic Information
| Provider Information | |||||||||
| NPI: | 1235425265 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALLARD | ||||||||
| FirstName: | JUSTINE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BCABA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | JUSTINE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1051 E 560 N | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846062047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7199305908 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7053 S 2310 W | ||||||||
| Address2: | |||||||||
| City: | WEST JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840843009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012555131 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2011 | ||||||||
| LastUpdateDate: | 02/13/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 0-11-4131 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.