Provider Demographics
NPI:1902526999
Name:BALLANTYNE, EMILY A (LMSW)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:A
Last Name:BALLANTYNE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:A
Other - Last Name:GALEGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11513 W FAIRVIEW AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-7887
Mailing Address - Country:US
Mailing Address - Phone:208-908-7882
Mailing Address - Fax:
Practice Address - Street 1:11513 W FAIRVIEW AVE STE 105
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-7887
Practice Address - Country:US
Practice Address - Phone:209-908-7882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID42611104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker