Provider Demographics
NPI:1548997562
Name:BALLANCE, TANJA LEE
Entity type:Individual
Prefix:
First Name:TANJA
Middle Name:LEE
Last Name:BALLANCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 MAPLE WAY
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4108
Mailing Address - Country:US
Mailing Address - Phone:307-389-0784
Mailing Address - Fax:
Practice Address - Street 1:1040 MAPLE WAY
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4108
Practice Address - Country:US
Practice Address - Phone:307-389-0784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health