Provider Demographics
NPI:1154447183
Name:BALLANTINE, GEORGE HERBERT (SLP)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:HERBERT
Last Name:BALLANTINE
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 OLD CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-8657
Mailing Address - Country:US
Mailing Address - Phone:505-890-9064
Mailing Address - Fax:
Practice Address - Street 1:266 OLD CHURCH RD
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-8657
Practice Address - Country:US
Practice Address - Phone:505-890-9064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM771235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist