Provider Demographics
NPI:1568016830
Name:BALLIEN, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:BALLIEN
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 1:8759 CLINTON MACON RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MI
Mailing Address - Zip Code:49236-9572
Mailing Address - Country:US
Mailing Address - Phone:989-755-1072
Mailing Address - Fax:
Practice Address - Street 1:3400 S WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-4958
Practice Address - Country:US
Practice Address - Phone:989-755-1072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CCAROtherCCAR