Provider Demographics
NPI:1487770137
Name:BALLOU, AMY V (BA)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:V
Last Name:BALLOU
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 RED JOHN DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32124-1016
Mailing Address - Country:US
Mailing Address - Phone:386-236-1812
Mailing Address - Fax:
Practice Address - Street 1:1150 RED JOHN DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32124-1016
Practice Address - Country:US
Practice Address - Phone:386-236-1812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor