Provider Demographics
NPI:1205400983
Name:BALLANCE, MICHAEL RAY (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAY
Last Name:BALLANCE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12270 KIRKWOOD ST
Mailing Address - Street 2:
Mailing Address - City:HERALD
Mailing Address - State:CA
Mailing Address - Zip Code:95638-9765
Mailing Address - Country:US
Mailing Address - Phone:209-663-8013
Mailing Address - Fax:
Practice Address - Street 1:825 W LOCKEFORD ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-1633
Practice Address - Country:US
Practice Address - Phone:209-331-7471
Practice Address - Fax:209-331-7464
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT184922251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics