Provider Demographics
NPI:1750523601
Name:BALLEW, RENEE MONIQUE (LMT)
Entity type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:MONIQUE
Last Name:BALLEW
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8325 SW MOHAWK ST.
Mailing Address - Street 2:APT #153
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062
Mailing Address - Country:US
Mailing Address - Phone:503-691-8572
Mailing Address - Fax:
Practice Address - Street 1:8325 SW MOHAWK ST.
Practice Address - Street 2:APT #153
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062
Practice Address - Country:US
Practice Address - Phone:503-691-8572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15069172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist