Provider Demographics
NPI:1033625462
Name:LIFE BALANCE INSTITUTE OF HEALING
Entity Type:Organization
Organization Name:LIFE BALANCE INSTITUTE OF HEALING
Other - Org Name:KELLEE ANNETTE MILES-MARANZ
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MFT CLINICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLEE
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:MILES-MARANZ
Authorized Official - Suffix:
Authorized Official - Credentials:MA MFT
Authorized Official - Phone:925-519-3375
Mailing Address - Street 1:1390 BROADWAY STE B297
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-5900
Mailing Address - Country:US
Mailing Address - Phone:925-519-3375
Mailing Address - Fax:925-666-4741
Practice Address - Street 1:1390 BROADWAY STE B297
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-5900
Practice Address - Country:US
Practice Address - Phone:925-519-3375
Practice Address - Fax:925-666-4741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-21
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA46894106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1316157555Medicaid