Provider Demographics
NPI:1932509064
Name:BALLANTYNE, VIRGINIA
Entity Type:Individual
Prefix:
First Name:VIRGINIA
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 1:151 W MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95110-1713
Mailing Address - Country:US
Mailing Address - Phone:408-535-4260
Mailing Address - Fax:408-280-7201
Practice Address - Street 1:151 W MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110-1713
Practice Address - Country:US
Practice Address - Phone:408-535-4260
Practice Address - Fax:408-280-7201
Is Sole Proprietor?:No
Enumeration Date:2014-08-26
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW674161041C0700X
104100000X
CALCSW982671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker