Provider Demographics
NPI:1043571185
Name:BALLOU, DENISE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:BALLOU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-2828
Mailing Address - Country:US
Mailing Address - Phone:914-447-3162
Mailing Address - Fax:
Practice Address - Street 1:136 CENTRE ST
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-2828
Practice Address - Country:US
Practice Address - Phone:914-447-3162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist