Provider Demographics
NPI:1023748407
Name:BALLANTINE, AMORY EW (LICSW)
Entity type:Individual
Prefix:
First Name:AMORY
Middle Name:EW
Last Name:BALLANTINE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:AMORY
Other - Middle Name:EW
Other - Last Name:VAN ORMAN-BALLANTINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:INFORMALLY USED
Mailing Address - Street 1:413 LILLY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5166
Mailing Address - Country:US
Mailing Address - Phone:360-491-9480
Mailing Address - Fax:360-456-2413
Practice Address - Street 1:413 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5133
Practice Address - Country:US
Practice Address - Phone:360-491-9480
Practice Address - Fax:360-456-2413
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW616527201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical