Provider Demographics
NPI:1982125332
Name:BALLINGER, SCOTT NICHOLAS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:NICHOLAS
Last Name:BALLINGER
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 1:1476 N PINEBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-2680
Mailing Address - Country:US
Mailing Address - Phone:909-843-5792
Mailing Address - Fax:
Practice Address - Street 1:1476 N PINEBROOK AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-2680
Practice Address - Country:US
Practice Address - Phone:909-843-5792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29441103T00000X
CAPSB94023080390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program