Provider Demographics
NPI:1659524262
Name:BALLOS, FAWNE N (OTR/L)
Entity Type:Individual
Prefix:
First Name:FAWNE
Middle Name:N
Last Name:BALLOS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 VALLEY VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-6410
Mailing Address - Country:US
Mailing Address - Phone:814-418-4496
Mailing Address - Fax:
Practice Address - Street 1:501 VALLEY VIEW BLVD
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-6410
Practice Address - Country:US
Practice Address - Phone:814-418-4496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC010777225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist