Provider Demographics
NPI:1104084763
Name:BALLENTINE, THOMAS K (LSW)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:K
Last Name:BALLENTINE
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 HUMBLE DR
Mailing Address - Street 2:
Mailing Address - City:DE GRAFF
Mailing Address - State:OH
Mailing Address - Zip Code:43318-9654
Mailing Address - Country:US
Mailing Address - Phone:937-524-6459
Mailing Address - Fax:
Practice Address - Street 1:6161 BUSCH BLVD STE 290
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-2587
Practice Address - Country:US
Practice Address - Phone:614-987-5003
Practice Address - Fax:614-987-5041
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH030102101YA0400X
OHS.2005473104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)