Provider Demographics
NPI:1841575735
Name:BALLE, MARY BETH (PMHCNS-BC, RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:BALLE
Suffix:
Gender:F
Credentials:PMHCNS-BC, RN
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Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5001
Practice Address - Country:US
Practice Address - Phone:812-335-2434
Practice Address - Fax:812-335-7604
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN28160285A163W00000X
IN2010016860163WP0807X
IN71003908A364SP0808X, 364SP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health