Provider Demographics
NPI:1376798231
Name:VONBALLMOOS, CHRISTINE I (LCSW)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:I
Last Name:VONBALLMOOS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 W BLUE HERON BLVD
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404-5003
Mailing Address - Country:US
Mailing Address - Phone:561-841-3500
Mailing Address - Fax:
Practice Address - Street 1:2001 W BLUE HERON BLVD
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-5003
Practice Address - Country:US
Practice Address - Phone:561-841-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-19
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW74071041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767166100Medicaid