Basic Information
| Provider Information | |||||||||
| NPI: | 1316135064 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALLINGER | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 155 INVERNESS DR W | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801125095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037799676 | ||||||||
| FaxNumber: | 3038894800 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 INVERNESS DR W | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801125095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037799676 | ||||||||
| FaxNumber: | 3038894800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2007 | ||||||||
| LastUpdateDate: | 04/24/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFT0001105 | CO | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YA0400X | ACC 0020817 | CO | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 05056 | 05 | WA | MEDICAID | 9002BA | 01 | REGENCE | OTHER |