Provider Demographics
NPI:1366083396
Name:BALL, STEPHEN RICHARD
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RICHARD
Last Name:BALL
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 1:2644 30TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3051
Mailing Address - Country:US
Mailing Address - Phone:310-314-6200
Mailing Address - Fax:310-450-2024
Practice Address - Street 1:909 PICO BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-1326
Practice Address - Country:US
Practice Address - Phone:310-314-6200
Practice Address - Fax:310-450-2024
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-01
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)