Provider Demographics
NPI:1306835574
Name:BALLY, DAVID (PT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BALLY
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 1:1681 WASHINGTON ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-7948
Mailing Address - Country:US
Mailing Address - Phone:781-843-4394
Mailing Address - Fax:781-843-1718
Practice Address - Street 1:1681 WASHINGTON ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-7948
Practice Address - Country:US
Practice Address - Phone:781-843-4394
Practice Address - Fax:781-843-1718
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7619225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY68277Medicare ID - Type Unspecified