Provider Demographics
NPI:1942466172
Name:BALLARD, CHARLES CHRISTOPHER (PTA4382)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:CHRISTOPHER
Last Name:BALLARD
Suffix:
Gender:M
Credentials:PTA4382
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 HIGHWAY 82 W STE B
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-5069
Mailing Address - Country:US
Mailing Address - Phone:662-455-5010
Mailing Address - Fax:662-455-5468
Practice Address - Street 1:702 HIGHWAY 82 W STE B
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-5069
Practice Address - Country:US
Practice Address - Phone:662-455-5010
Practice Address - Fax:662-455-5468
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA4382225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant