Provider Demographics
NPI:1821345372
Name:BALLEWSKE, DANA MICHELLE (PSY D)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:MICHELLE
Last Name:BALLEWSKE
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2108 63RD ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-4454
Mailing Address - Country:US
Mailing Address - Phone:262-652-2406
Mailing Address - Fax:
Practice Address - Street 1:2108 63RD ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-4454
Practice Address - Country:US
Practice Address - Phone:262-652-2406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3646103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical