Provider Demographics
NPI:1538270483
Name:BALLENGER, KENNETH BRUK (PT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:BRUK
Last Name:BALLENGER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:BRUK
Other - Middle Name:
Other - Last Name:BALLENGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, CSCS
Mailing Address - Street 1:23636 HIGHWAY 99
Mailing Address - Street 2:SUITE F
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026
Mailing Address - Country:US
Mailing Address - Phone:206-788-8807
Mailing Address - Fax:866-329-2785
Practice Address - Street 1:19022 AURORA AVE N STE B
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-3915
Practice Address - Country:US
Practice Address - Phone:206-788-8807
Practice Address - Fax:866-329-2785
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT7473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA165921OtherWA STATE L&I
WA8331621Medicaid
WA165921OtherWA STATE L&I