Healthcare Provider Details

I. General information

NPI: 1467006718
Provider Name (Legal Business Name): KYLE DEAN BALLENTINE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2019
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 E FOOTHILL BLVD STE 102
ARCADIA CA
91006-2361
US

IV. Provider business mailing address

41 E FOOTHILL BLVD STE 102
ARCADIA CA
91006-2361
US

V. Phone/Fax

Practice location:
  • Phone: 626-701-4249
  • Fax:
Mailing address:
  • Phone: 626-701-4249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number114496
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: