Provider Demographics
NPI:1386712313
Name:BALLOU, AMY JEAN (OTD OTR)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JEAN
Last Name:BALLOU
Suffix:
Gender:F
Credentials:OTD OTR
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:JEAN
Other - Last Name:KRATZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTD OTR
Mailing Address - Street 1:2420 RIVER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-2045
Mailing Address - Country:US
Mailing Address - Phone:515-327-8645
Mailing Address - Fax:
Practice Address - Street 1:1978 GRAND AVE STE 45
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-4217
Practice Address - Country:US
Practice Address - Phone:515-221-2220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01310225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA46281OtherWELLMARK