Provider Demographics
NPI:1710016845
Name:BALLOU, CONSTANCE P (OTR/L CHT)
Entity Type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:P
Last Name:BALLOU
Suffix:
Gender:F
Credentials:OTR/L CHT
Other - Prefix:
Other - First Name:CONSTANCE
Other - Middle Name:
Other - Last Name:PASEK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12910 TOTEM LAKE BLVD NE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-2954
Mailing Address - Country:US
Mailing Address - Phone:888-924-2631
Mailing Address - Fax:425-924-2630
Practice Address - Street 1:11126 NE 104TH WAY
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-5034
Practice Address - Country:US
Practice Address - Phone:425-827-9594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00002332225X00000X
WA9105000876225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA115763OtherL AND I
WABA5492OtherREGENCE
WA7680697Medicaid
AB33148Medicare PIN