Provider Demographics
NPI:1114577699
Name:BALLAM, BRYNDIE MARISE
Entity Type:Individual
Prefix:
First Name:BRYNDIE
Middle Name:MARISE
Last Name:BALLAM
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 1:4501 GASTON ST
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-2244
Mailing Address - Country:US
Mailing Address - Phone:202-760-1433
Mailing Address - Fax:
Practice Address - Street 1:45305 CATALINA CT BLDG B
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-2369
Practice Address - Country:US
Practice Address - Phone:571-441-3177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst