Provider Demographics
NPI:1861745176
Name:BALLENTHIN, MATTHEW E (PSYD LP)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:E
Last Name:BALLENTHIN
Suffix:
Gender:M
Credentials:PSYD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8550 HUDSON BLVD N
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-5500
Practice Address - Country:US
Practice Address - Phone:651-254-8580
Practice Address - Fax:651-254-0601
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5527103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical