Provider Demographics
NPI:1033250873
Name:SHEILA A. BALOG, PH.D., PC
Entity Type:Organization
Organization Name:SHEILA A. BALOG, PH.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BALOG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:678-583-4975
Mailing Address - Street 1:55 JONESBORO ST
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-3164
Mailing Address - Country:US
Mailing Address - Phone:678-583-4975
Mailing Address - Fax:
Practice Address - Street 1:55 JONESBORO ST
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-3164
Practice Address - Country:US
Practice Address - Phone:678-583-4975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY2369261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00857073CMedicaid