Provider Demographics
NPI:1366713364
Name:BALLENGER, KHRYSTIN (LMFT)
Entity type:Individual
Prefix:MRS
First Name:KHRYSTIN
Middle Name:
Last Name:BALLENGER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MISS
Other - First Name:KHRYSTIN
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:380 SUWANNEE TRAIL ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7956
Mailing Address - Country:US
Mailing Address - Phone:270-901-5000
Mailing Address - Fax:
Practice Address - Street 1:380 SUWANNEE TRAIL ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7956
Practice Address - Country:US
Practice Address - Phone:270-901-5000
Practice Address - Fax:270-842-5268
Is Sole Proprietor?:No
Enumeration Date:2012-01-23
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY164357106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100372860Medicaid