Provider Demographics
NPI:1073365243
Name:BLUE BALLOON INDIAN CREEK LLC
Entity Type:Organization
Organization Name:BLUE BALLOON INDIAN CREEK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWMARK
Authorized Official - Suffix:
Authorized Official - Credentials:MED, BCBA, LBA
Authorized Official - Phone:201-216-9500
Mailing Address - Street 1:175 BELGROVE DR
Mailing Address - Street 2:
Mailing Address - City:KEARNY
Mailing Address - State:NJ
Mailing Address - Zip Code:07032-1507
Mailing Address - Country:US
Mailing Address - Phone:201-216-9500
Mailing Address - Fax:
Practice Address - Street 1:12240 INDIAN CREEK CT STE 100
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-1242
Practice Address - Country:US
Practice Address - Phone:201-216-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty