Healthcare Provider Details

I. General information

NPI: 1235880329
Provider Name (Legal Business Name): BLUE BALLOON NC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8601 SIX FORKS ROAD, SUITE 400, OFFICE 444
RALEIGH NC
27615-5276
US

IV. Provider business mailing address

175 BELGROVE DR
KEARNY NJ
07032-1507
US

V. Phone/Fax

Practice location:
  • Phone: 551-302-0306
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

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