Provider Demographics
NPI:1558749945
Name:BALLIETT, WHITNEY (LADC)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:
Last Name:BALLIETT
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 717
Mailing Address - Street 2:
Mailing Address - City:CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06018-0717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:187 S CANAAN RD
Practice Address - Street 2:
Practice Address - City:CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06018-2544
Practice Address - Country:US
Practice Address - Phone:860-824-1397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1038101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)