Provider Demographics
NPI:1164878286
Name:BALLAGE, OLIVIA SHAE (RBT)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:SHAE
Last Name:BALLAGE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8289 FORT SMITH RD
Mailing Address - Street 2:
Mailing Address - City:FALCON
Mailing Address - State:CO
Mailing Address - Zip Code:80831-7937
Mailing Address - Country:US
Mailing Address - Phone:719-243-7866
Mailing Address - Fax:
Practice Address - Street 1:1155 KELLY JOHNSON BLVD STE 150
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3931
Practice Address - Country:US
Practice Address - Phone:719-354-2582
Practice Address - Fax:720-493-4632
Is Sole Proprietor?:No
Enumeration Date:2016-05-07
Last Update Date:2016-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-16-13105103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
COR410449Medicaid