Healthcare Provider Details

I. General information

NPI: 1386883312
Provider Name (Legal Business Name): DINO DOMINIC BALLIVIERO LPC, CTTS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2009
Last Update Date: 06/20/2020
Certification Date: 06/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71338 HWY. 21 SUITE 101
COVINGTON LA
70433-7162
US

IV. Provider business mailing address

203 LEEDS ST
SLIDELL LA
70461-5061
US

V. Phone/Fax

Practice location:
  • Phone: 985-624-2942
  • Fax: 985-231-1373
Mailing address:
  • Phone: 985-643-3669
  • Fax: 985-643-3669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2732
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: