Provider Demographics
NPI:1023461993
Name:BALLANTYNE, ROBERT (PSYD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:BALLANTYNE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W BELMONT AVE
Mailing Address - Street 2:SUITE 508, C/O CATHARINE DEVLIN
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 W BELMONT AVE
Practice Address - Street 2:SUITE 508, C/O CATHARINE DEVLIN
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3200
Practice Address - Country:US
Practice Address - Phone:313-282-1156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-15
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008958103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical