Provider Demographics
NPI:1538379425
Name:BALLARD, TIM SCOTT (LCPC)
Entity type:Individual
Prefix:
First Name:TIM
Middle Name:SCOTT
Last Name:BALLARD
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 S 4TH ST W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-2629
Mailing Address - Country:US
Mailing Address - Phone:406-240-7924
Mailing Address - Fax:
Practice Address - Street 1:519 S 4TH ST W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-2629
Practice Address - Country:US
Practice Address - Phone:406-240-7924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1154101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0256496Medicaid
MT741820OtherBLUE CROSS BLUE SHIELD