Provider Demographics
NPI:1023893864
Name:BALLARD, DORIAN IMANI
Entity type:Individual
Prefix:
First Name:DORIAN
Middle Name:IMANI
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 1:26150 SUMMERDALE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-6135
Mailing Address - Country:US
Mailing Address - Phone:248-495-6789
Mailing Address - Fax:
Practice Address - Street 1:26150 SUMMERDALE DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-6135
Practice Address - Country:US
Practice Address - Phone:248-495-6789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare