Provider Demographics
NPI:1992968630
Name:BALLARD, DWIGHT DAVIS (MSW)
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:DAVIS
Last Name:BALLARD
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1357 GOFFMAN ROAD
Mailing Address - Street 2:
Mailing Address - City:EASTOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29044-8728
Mailing Address - Country:US
Mailing Address - Phone:803-782-1421
Mailing Address - Fax:
Practice Address - Street 1:3201 TRENHOLM ROAD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-3371
Practice Address - Country:US
Practice Address - Phone:803-782-1421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC85851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical