Provider Demographics
NPI:1235293176
Name:BALLON, GAIL (RPT)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:BALLON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 W RIVIERA CT
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-2025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8615 KNOTT AVE
Practice Address - Street 2:SUITE 8
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-3841
Practice Address - Country:US
Practice Address - Phone:562-484-3860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT28779AMedicare ID - Type UnspecifiedORANGE COUNTY PPIN