Provider Demographics
NPI:1609613363
Name:BALLARD, LOGAN MICHAEL
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:MICHAEL
Last Name:BALLARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14191 W CALAVAR RD
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-8623
Mailing Address - Country:US
Mailing Address - Phone:623-755-7360
Mailing Address - Fax:
Practice Address - Street 1:2355 W LEMARCHE AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-4122
Practice Address - Country:US
Practice Address - Phone:602-688-6925
Practice Address - Fax:602-296-0414
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRBT-24-357282106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician