Provider Demographics
NPI:1235471145
Name:BALLOU, MADONNA (OTR/L, PTA)
Entity type:Individual
Prefix:
First Name:MADONNA
Middle Name:
Last Name:BALLOU
Suffix:
Gender:F
Credentials:OTR/L, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 EBENSBERGER AVE
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-2409
Mailing Address - Country:US
Mailing Address - Phone:830-446-1445
Mailing Address - Fax:
Practice Address - Street 1:1635 NE LOOP 410
Practice Address - Street 2:SUITE 600
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-1625
Practice Address - Country:US
Practice Address - Phone:210-457-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-19
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117960225X00000X
TX2077540225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant