Provider Demographics
NPI:1528542925
Name:BALAWON, JOYCE NIBATEN
Entity Type:Individual
Prefix:
First Name:JOYCE
Middle Name:NIBATEN
Last Name:BALAWON
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 1:2130 ANDERSON MILL RD
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1806
Mailing Address - Country:US
Mailing Address - Phone:770-941-8813
Mailing Address - Fax:
Practice Address - Street 1:2130 ANDERSON MILL RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1806
Practice Address - Country:US
Practice Address - Phone:770-941-8813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003588225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA057816618OtherGEORGIA DEPARTMENT OF DRIVERS SERVICES
GA003588OtherGEORGIA STATE BOARD OF PHYSICAL THERAPY