Provider Demographics
NPI:1427244045
Name:BALAJADIA, MAMIE CAMPBELL
Entity type:Individual
Prefix:DR
First Name:MAMIE
Middle Name:CAMPBELL
Last Name:BALAJADIA
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 1:520 WEST SANTA MONICA DRIVE
Mailing Address - Street 2:
Mailing Address - City:DEDEDO
Mailing Address - State:GU
Mailing Address - Zip Code:96912
Mailing Address - Country:US
Mailing Address - Phone:671-635-7492
Mailing Address - Fax:671-635-7493
Practice Address - Street 1:520 WEST SANTA MONICA DRIVE
Practice Address - Street 2:
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96912
Practice Address - Country:US
Practice Address - Phone:671-635-7492
Practice Address - Fax:671-635-7493
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUCP003103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical