Provider Demographics
NPI:1356697254
Name:BALLISTY, BRIDGETT
Entity type:Individual
Prefix:MS
First Name:BRIDGETT
Middle Name:
Last Name:BALLISTY
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 1:230 E DUNNE AVE
Mailing Address - Street 2:APT #1322
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037-4654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7877 WREN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-4980
Practice Address - Country:US
Practice Address - Phone:408-905-6594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-28
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health