1962179689 NPI number — BALANCED LIVING PSYCHOLOGICAL SOLUTIONS

Table of content: (NPI 1962179689)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962179689 NPI number — BALANCED LIVING PSYCHOLOGICAL SOLUTIONS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALANCED LIVING PSYCHOLOGICAL SOLUTIONS
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:
CENTER FOR BALANCED LIVING
Provider Other Organization Name Type Code:
3
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:
1962179689
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5879 SUMMIT BRIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOWNSEND
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19734-9375
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-608-3780
Provider Business Mailing Address Fax Number:
302-355-3226

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5879 SUMMIT BRIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOWNSEND
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19734-9375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-608-3780
Provider Business Practice Location Address Fax Number:
302-355-3226
Provider Enumeration Date:
08/30/2021

Additional Information

Authorized Official

Authorized Official Last Name:
SERRAVALLE
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
302-824-3722

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 250741282 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: PC-0000607 . This is a "LICENSED PROFESSIONAL COUNSELOR OF MENTAL HEALTH" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: B1-0011250 . This is a "LICENSED PSYCHOLOGIST" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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