1710016845 NPI number — MRS. CONSTANCE P BALLOU OTR/L CHT

Table of content: MRS. CONSTANCE P BALLOU OTR/L CHT (NPI 1710016845)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710016845 NPI number — MRS. CONSTANCE P BALLOU OTR/L CHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALLOU
Provider First Name:
CONSTANCE
Provider Middle Name:
P
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR/L CHT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PASEK
Provider Other First Name:
CONSTANCE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1710016845
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12910 TOTEM LAKE BLVD NE
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
KIRKLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98034-2954
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-924-2631
Provider Business Mailing Address Fax Number:
425-924-2630

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11126 NE 104TH WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KIRKLAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98033-5034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-827-9594
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  OT00002332 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XH1200X , with the licence number: 9105000876 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 115763 . This is a "L AND I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: BA5492 . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7680697 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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