Provider Demographics
NPI:1861465817
Name:BALL, LAWRENCE B (PSYD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:B
Last Name:BALL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:SANTA CLAUS
Mailing Address - State:IN
Mailing Address - Zip Code:47579-0719
Mailing Address - Country:US
Mailing Address - Phone:310-951-3894
Mailing Address - Fax:
Practice Address - Street 1:100 N LOUIS J KOCH BLVD # 203
Practice Address - Street 2:
Practice Address - City:SANTA CLAUS
Practice Address - State:IN
Practice Address - Zip Code:47579-8540
Practice Address - Country:US
Practice Address - Phone:310-951-3894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18983103TC0700X
IN20042996A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP18983Medicare ID - Type Unspecified