Provider Demographics
NPI:1477625960
Name:BALLIETT, MARY E (DC)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:BALLIETT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 W BUFFALO ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-4132
Mailing Address - Country:US
Mailing Address - Phone:607-256-0641
Mailing Address - Fax:607-256-0641
Practice Address - Street 1:116 W BUFFALO ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4132
Practice Address - Country:US
Practice Address - Phone:607-256-0641
Practice Address - Fax:607-256-0641
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX005480-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYDD7078Medicare ID - Type UnspecifiedCHIROPRACTIC
NYT26781Medicare UPIN