Provider Demographics
NPI:1043350077
Name:BALENTINE, ROBERT WADE (PHD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:WADE
Last Name:BALENTINE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17005 TEAL CT
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20855-2060
Mailing Address - Country:US
Mailing Address - Phone:301-789-1932
Mailing Address - Fax:
Practice Address - Street 1:19590 CLUB HOUSE RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY VILLAGE
Practice Address - State:MD
Practice Address - Zip Code:20886-3002
Practice Address - Country:US
Practice Address - Phone:301-948-5414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00416103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist