Provider Demographics
NPI:1487255535
Name:BALLARD, BLAKE A (PTA)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:A
Last Name:BALLARD
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MS
Mailing Address - Zip Code:39654-0457
Mailing Address - Country:US
Mailing Address - Phone:601-587-2563
Mailing Address - Fax:601-587-0472
Practice Address - Street 1:314 MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MS
Practice Address - Zip Code:39654-3702
Practice Address - Country:US
Practice Address - Phone:601-587-2563
Practice Address - Fax:601-587-0472
Is Sole Proprietor?:No
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA6757225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSPTA6757OtherMS STATE BOARD OF PHYSICAL THERAPY