Provider Demographics
NPI:1659528651
Name:BALLANTYNE, ROSARIO
Entity Type:Individual
Prefix:
First Name:ROSARIO
Middle Name:
Last Name:BALLANTYNE
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 1:484 E SAN FERNANDO ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-3513
Mailing Address - Country:US
Mailing Address - Phone:408-293-0422
Mailing Address - Fax:
Practice Address - Street 1:484 E SAN FERNANDO ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-3513
Practice Address - Country:US
Practice Address - Phone:408-293-0422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1334OtherUNICARE USER