1083153837 NPI number — A BALANCED LIFE: INDIVIDUAL, FAMILY AND CHILD THERAPY, INC

Table of content: (NPI 1083153837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083153837 NPI number — A BALANCED LIFE: INDIVIDUAL, FAMILY AND CHILD THERAPY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
A BALANCED LIFE: INDIVIDUAL, FAMILY AND CHILD THERAPY, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083153837
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7152
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH LAKE TAHOE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96158-0152
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-544-1748
Provider Business Mailing Address Fax Number:
530-544-1728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 ELOISE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH LAKE TAHOE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96150-4306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-544-1748
Provider Business Practice Location Address Fax Number:
530-544-1728
Provider Enumeration Date:
02/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SIMON
Authorized Official First Name:
LINDSAY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/CLINICAL DIRECTOR
Authorized Official Telephone Number:
530-544-1748

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LCSW24256 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com