Provider Demographics
NPI:1891674628
Name:BALLARD, CULLEN
Entity type:Individual
Prefix:
First Name:CULLEN
Middle Name:
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 1:1322 ELTON RD STE I
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-4100
Mailing Address - Country:US
Mailing Address - Phone:337-824-5488
Mailing Address - Fax:
Practice Address - Street 1:4150 NELSON RD STE 1
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4148
Practice Address - Country:US
Practice Address - Phone:337-660-2996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-27
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist