Provider Demographics
NPI:1124478813
Name:BALLOU, DANIEL
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:BALLOU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4932 SOUTHPOINT PKWY
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-2659
Mailing Address - Country:US
Mailing Address - Phone:540-891-1186
Mailing Address - Fax:
Practice Address - Street 1:4932 SOUTHPOINT PKWY
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-2659
Practice Address - Country:US
Practice Address - Phone:540-891-1186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305210335225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist