Healthcare Provider Details

I. General information

NPI: 1871580779
Provider Name (Legal Business Name): PERCY BALLANTINE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 03/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ANNA MARSH LANE
BRATTLEBORO VT
05302-0803
US

IV. Provider business mailing address

ANNA MARSH LANE
BRATTLEBORO VT
05302-0803
US

V. Phone/Fax

Practice location:
  • Phone: 802-257-7785
  • Fax:
Mailing address:
  • Phone: 802-257-7785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number042-0005715
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number042-0005715
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: