Healthcare Provider Details

I. General information

NPI: 1629646492
Provider Name (Legal Business Name): BLUE BALLOON MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 REDLAND CT STE 102
OWINGS MILLS MD
21117-3265
US

IV. Provider business mailing address

500 REDLAND CT STE 102
OWINGS MILLS MD
21117-3265
US

V. Phone/Fax

Practice location:
  • Phone: 201-216-9500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: DAVID SUSSMAN
Title or Position: COO
Credential:
Phone: 201-216-9500