Basic Information
Provider Information
NPI: 1073069985
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BALLAS
FirstName: THERESA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: LAC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 42 DELSEA DR S
Address2:  
City: GLASSBORO
State: NJ
PostalCode: 080282621
CountryCode: US
TelephoneNumber: 8568818689
FaxNumber: 8568815508
Practice Location
Address1: 42 DELSEA DR S
Address2:  
City: GLASSBORO
State: NJ
PostalCode: 080282621
CountryCode: US
TelephoneNumber: 8568818689
FaxNumber: 8568815508
Other Information
ProviderEnumerationDate: 08/31/2016
LastUpdateDate: 08/31/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YP2500X37AC00300100NJY Behavioral Health & Social Service ProvidersCounselorProfessional
101Y00000X101YP2500XNJN Behavioral Health & Social Service ProvidersCounselor 

No ID Information.


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