Basic Information
| Provider Information | |||||||||
| NPI: | 1487807764 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALLARD | ||||||||
| FirstName: | BRITTANY | ||||||||
| MiddleName: | BH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MHRT-CSP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAINES | ||||||||
| OtherFirstName: | BRITTANY | ||||||||
| OtherMiddleName: | B | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 43 HATCH DRIVE | ||||||||
| Address2: | |||||||||
| City: | CARIBOU | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047360000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074986431 | ||||||||
| FaxNumber: | 2074923181 | ||||||||
| Practice Location | |||||||||
| Address1: | 43 HATCH DR | ||||||||
| Address2: | |||||||||
| City: | CARIBOU | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047362161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074986431 | ||||||||
| FaxNumber: | 2074923181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2008 | ||||||||
| LastUpdateDate: | 07/22/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ME | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 103850000 | 01 | ME | MAINECARE | OTHER |