Provider Demographics
NPI:1497291603
Name:BALLANCE, EDWARD GEORGE JR (MACP, MAC, LLPC)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:GEORGE
Last Name:BALLANCE
Suffix:JR
Gender:M
Credentials:MACP, MAC, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4467 CASCADE RD SE STE 4469
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3776
Mailing Address - Country:US
Mailing Address - Phone:616-648-3943
Mailing Address - Fax:
Practice Address - Street 1:4467 CASCADE RD SE STE 4469
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3776
Practice Address - Country:US
Practice Address - Phone:616-648-3943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015086101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional