1063855609 NPI number — BALANCED LIVING THERAPY, LLC

Table of content: (NPI 1063855609)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063855609 NPI number — BALANCED LIVING THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALANCED LIVING THERAPY, LLC
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:
1063855609
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7500 212TH ST SW STE 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDMONDS
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98026-7617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-977-4988
Provider Business Mailing Address Fax Number:
425-977-4989

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7500 212TH ST SW STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMONDS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98026-7617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-977-4988
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ISHAQ
Authorized Official First Name:
MAGGIE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER/LICENSED MENTAL HEALTH COUNS
Authorized Official Telephone Number:
425-977-4988

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 916313 . This is a "CARPENTERS HEALTH AND SECURITY PLAN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2150671 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 909035 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 912650 . This is a "LIFEWISE OF WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1950283 . This is a "PROVIDENCE HEALTH PLAN OF WASHINGTON" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1253932 . This is a "KAISER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1560659 . This is a "MOLINA HEALTH CARE OF WASHINGTON" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 909040 . This is a "FIRST CHOICE HEALTH NETWORK" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1554873 . This is a "COMMUNITY HEALTH PLAN OF WASHINGTON" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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