Provider Demographics
NPI:1508633082
Name:ITANI, BALSAM (DPT)
Entity Type:Individual
Prefix:
First Name:BALSAM
Middle Name:
Last Name:ITANI
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5510 HIGHWAY 187
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29625-6344
Mailing Address - Country:US
Mailing Address - Phone:571-732-9958
Mailing Address - Fax:
Practice Address - Street 1:1403 E GREENVILLE ST STE B
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-2285
Practice Address - Country:US
Practice Address - Phone:864-225-7552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11939225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist