Provider Demographics
NPI:1548717325
Name:BALUYOT, MICAH CAMILLE TALUSAN (ATC)
Entity type:Individual
Prefix:
First Name:MICAH CAMILLE
Middle Name:TALUSAN
Last Name:BALUYOT
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DANFORTH AVE
Mailing Address - Street 2:APT 1B
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305-1928
Mailing Address - Country:US
Mailing Address - Phone:551-208-3763
Mailing Address - Fax:
Practice Address - Street 1:325 DANFORTH AVE
Practice Address - Street 2:APT 1B
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07305-1928
Practice Address - Country:US
Practice Address - Phone:551-208-3763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002291002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer