Provider Demographics
NPI:1972905800
Name:BALTES, ASHLEY (LMSW)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:BALTES
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-0547
Mailing Address - Country:US
Mailing Address - Phone:843-663-8000
Mailing Address - Fax:
Practice Address - Street 1:3236 HOLMESTOWN RD
Practice Address - Street 2:SUITE E-1
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-7495
Practice Address - Country:US
Practice Address - Phone:843-663-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10874104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCLW1025Medicaid
SCLW1025Medicaid