Provider Demographics
NPI:1194544247
Name:BALLARD, MALAYSIA EBONIE
Entity type:Individual
Prefix:
First Name:MALAYSIA
Middle Name:EBONIE
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 1:1314 PINCHOT ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-3640
Mailing Address - Country:US
Mailing Address - Phone:209-346-1047
Mailing Address - Fax:
Practice Address - Street 1:1314 PINCHOT ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-3640
Practice Address - Country:US
Practice Address - Phone:209-346-1047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician