Provider Demographics
NPI:1982707279
Name:BALLIS, THOMAS ANTHONY (LCSW, LCAS)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:ANTHONY
Last Name:BALLIS
Suffix:
Gender:M
Credentials:LCSW, LCAS
Other - Prefix:
Other - First Name:TAB
Other - Middle Name:
Other - Last Name:BALLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW, LCAS
Mailing Address - Street 1:720 N 3RD ST
Mailing Address - Street 2:STE 101
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-3474
Mailing Address - Country:US
Mailing Address - Phone:910-251-2106
Mailing Address - Fax:910-251-7859
Practice Address - Street 1:720 N 3RD ST
Practice Address - Street 2:STE 101
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-3474
Practice Address - Country:US
Practice Address - Phone:910-251-2106
Practice Address - Fax:910-251-7859
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC447101YA0400X
NCC0021211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002056Medicaid