MEDICARE: CHRISTINE NICOLE BRACAMONTES BALLANCE MA, LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	180011136	IL

General Provider Information

NPI Number	:	1982122214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE NICOLE BRACAMONTES BALLANCE MA, LCPC

Provider Business Mailing Address
First Line	:	226 S MORRISON AVE
Second Line	:
City	:	COLLINSVILLE
State	:	IL
Zip	:	62234-2711
Country	:	US
Telephone Number	:	618-514-4842
Fax Number	:	618-514-4842

Provider Business Practice Location Address
First Line	:	226 S MORRISON AVE
Second Line	:
City	:	COLLINSVILLE
State	:	IL
Zip	:	62234-2711
Country	:	US
Telephone Number	:	618-514-4842
Fax Number	:	618-514-4842

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2017
Last Update Date	:	03/25/2019

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