Provider Demographics
NPI:1275823288
Name:BALLANTINE, BRENDA DARLENE (MA)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:DARLENE
Last Name:BALLANTINE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 REEDS AVE
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-4273
Mailing Address - Country:US
Mailing Address - Phone:530-200-1452
Mailing Address - Fax:
Practice Address - Street 1:4343 WILLIAMSBURG DR.
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823
Practice Address - Country:US
Practice Address - Phone:916-473-5766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor