Provider Demographics
NPI:1083386049
Name:BALLARD, RILEY K (PT)
Entity type:Individual
Prefix:
First Name:RILEY
Middle Name:K
Last Name:BALLARD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:715-526-7370
Mailing Address - Fax:715-526-7294
Practice Address - Street 1:370 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54929-1632
Practice Address - Country:US
Practice Address - Phone:715-526-7370
Practice Address - Fax:715-526-7294
Is Sole Proprietor?:No
Enumeration Date:2021-09-29
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
225100000X
WI16656225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist