Basic Information
| Provider Information | |||||||||
| NPI: | 1841575735 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALLE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | PMHCNS-BC, RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 350 S LANDMARK AVE | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474035001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123352434 | ||||||||
| FaxNumber: | 8123357604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2011 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 28160285A | IN | N | Nursing Service Providers | Registered Nurse | 163WP0807X | 2010016860 | IN | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Child & Adolescent | 364SP0808X | 71003908A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health | 364SP0807X | 71003908A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Child & Adolescent |
No ID Information.