Provider Demographics
NPI:1710314984
Name:BALLENER, LYN JONSON
Entity Type:Individual
Prefix:MISS
First Name:LYN
Middle Name:JONSON
Last Name:BALLENER
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 1:64 TUERS AVE
Mailing Address - Street 2:#2C JERSEY CITY
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-3250
Mailing Address - Country:US
Mailing Address - Phone:201-850-0619
Mailing Address - Fax:
Practice Address - Street 1:824 55TH STREET (BET. 8TH & 9TH AVE.)
Practice Address - Street 2:BROOKLYN
Practice Address - City:NY
Practice Address - State:NY
Practice Address - Zip Code:11220
Practice Address - Country:US
Practice Address - Phone:718-686-1733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032523225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist