Provider Demographics
NPI:1417164757
Name:BALLENGER, LAURA M
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:BALLENGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 S COIT ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-5220
Mailing Address - Country:US
Mailing Address - Phone:843-407-1565
Mailing Address - Fax:843-407-6748
Practice Address - Street 1:517 S COIT ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-5220
Practice Address - Country:US
Practice Address - Phone:843-407-1565
Practice Address - Fax:843-407-6748
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5283104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC376241Medicaid
SC3337Medicare ID - Type Unspecified