Provider Demographics
NPI:1578651410
Name:BALLANTYNE, WILLIAM J (PSYD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:BALLANTYNE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 HANOVER ST
Mailing Address - Street 2:SUITE 2 WEST CENTRAL SERVICES INC
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766
Mailing Address - Country:US
Mailing Address - Phone:603-448-0126
Mailing Address - Fax:603-448-6001
Practice Address - Street 1:18 BAILEY AVE
Practice Address - Street 2:CLAREMONT CHILD AND FAMILY CTR
Practice Address - City:CLAREMONT
Practice Address - State:NH
Practice Address - Zip Code:03743
Practice Address - Country:US
Practice Address - Phone:603-542-5449
Practice Address - Fax:603-542-5455
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH739103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
BARE5812Medicare ID - Type Unspecified