1265149835 NPI number — LIVING BALANCE PSYCHOTHERAPY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265149835 NPI number — LIVING BALANCE PSYCHOTHERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVING BALANCE PSYCHOTHERAPY 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:
1265149835
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3470 MCCLURE BRIDGE RD UNIT 2511
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30096-1125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2810 PEACHTREE INDUSTRIAL BLVD STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30097-8142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-919-8496
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2022

Additional Information

Authorized Official

Authorized Official Last Name:
GILLMAN
Authorized Official First Name:
ANN
Authorized Official Middle Name:
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
404-919-8496

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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