Provider Demographics
NPI:1962952200
Name:BALAWENDER, MARK STANLEY (LMT, MMPD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:STANLEY
Last Name:BALAWENDER
Suffix:
Gender:M
Credentials:LMT, MMPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11932 ROSETHORN DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-3301
Mailing Address - Country:US
Mailing Address - Phone:413-441-1746
Mailing Address - Fax:
Practice Address - Street 1:11932 ROSETHORN DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-3301
Practice Address - Country:US
Practice Address - Phone:413-441-1746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT122520225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist