Basic Information
| Provider Information | |||||||||
| NPI: | 1164878286 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALLAGE | ||||||||
| FirstName: | OLIVIA | ||||||||
| MiddleName: | SHAE | ||||||||
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| Credential: | R.B.T | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8289 FORT SMITH RD | ||||||||
| Address2: | |||||||||
| City: | FALCON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808317937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192437866 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1155 KELLY JOHNSON BLVD STE 150 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809203931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193542582 | ||||||||
| FaxNumber: | 7204934632 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2016 | ||||||||
| LastUpdateDate: | 05/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | RBT-16-13105 | CO | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | R410449 | 05 | CO | MEDICAID |