Provider Demographics
NPI:1699115923
Name:BALLASCH, WENDY (LMT)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:BALLASCH
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 1:118 BERGER PL NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-5102
Mailing Address - Country:US
Mailing Address - Phone:850-543-4756
Mailing Address - Fax:850-855-9812
Practice Address - Street 1:184 BROOKS ST SE UNIT 1
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-2822
Practice Address - Country:US
Practice Address - Phone:850-543-4756
Practice Address - Fax:850-855-9812
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA31025225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist