Provider Demographics
NPI:1366064313
Name:BALLOU, MONICA LOTORIA
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:LOTORIA
Last Name:BALLOU
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 1:1345 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-3721
Mailing Address - Country:US
Mailing Address - Phone:434-429-2649
Mailing Address - Fax:
Practice Address - Street 1:1345 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-3721
Practice Address - Country:US
Practice Address - Phone:434-429-2649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities