Provider Demographics
NPI:1558485490
Name:BALLOU, BRONWEN B (LICSW)
Entity Type:Individual
Prefix:MS
First Name:BRONWEN
Middle Name:B
Last Name:BALLOU
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 DRESDEN RD
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03755-1322
Mailing Address - Country:US
Mailing Address - Phone:603-643-8838
Mailing Address - Fax:
Practice Address - Street 1:367 STATE ROUTE 120
Practice Address - Street 2:SUITE B1
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-1430
Practice Address - Country:US
Practice Address - Phone:603-653-0199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH9491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007467Medicaid
14Y000923NH01OtherBCBS OF NH
NH30420957Medicaid
400420OtherMVP
14Y000923NH01OtherFEDERAL BCBS
49549OtherMAGELLAN
49549OtherBCBS OF VT
7728098OtherAETNA