1982122214 NPI number — CHRISTINE NICOLE BRACAMONTES BALLANCE MA, LCPC

Table of content: CHRISTINE NICOLE BRACAMONTES BALLANCE MA, LCPC (NPI 1982122214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982122214 NPI number — CHRISTINE NICOLE BRACAMONTES BALLANCE MA, LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALLANCE
Provider First Name:
CHRISTINE
Provider Middle Name:
NICOLE BRACAMONTES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRACAMONTES
Provider Other First Name:
CHRISTINE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1982122214
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
226 S MORRISON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLINSVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62234-2711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-514-4842
Provider Business Mailing Address Fax Number:
618-514-4842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
226 S MORRISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLINSVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62234-2711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-514-4842
Provider Business Practice Location Address Fax Number:
618-514-4842
Provider Enumeration Date:
09/07/2017

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: 101YP2500X , with the licence number:  180011136 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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