Provider Demographics
NPI:1174605810
Name:BALAVENDER, ALAN (MS PT)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:BALAVENDER
Suffix:
Gender:M
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 DEPOT ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-2601
Mailing Address - Country:US
Mailing Address - Phone:860-274-4092
Mailing Address - Fax:860-274-4099
Practice Address - Street 1:27 DEPOT ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-2601
Practice Address - Country:US
Practice Address - Phone:860-274-4092
Practice Address - Fax:860-274-4099
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3638225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080003638CT12OtherANTHEM BC BS
CT080003638CT13OtherANTHEM BC BS
CT080003638CT15OtherBLUE SHIELD
CT080003638CT09OtherANTHEM BLUE CROSS BLUE SH
CT080003638CT10OtherANTHEM BC BS
CT004201018Medicaid
CT080003638CT14OtherBLUE SHIELD
CT080003638CT09OtherANTHEM BLUE CROSS BLUE SH