Provider Demographics
NPI:1043850696
Name:BALSEIRO, LEO TIMOTHY MICHAEL (LMHC, NCC)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:TIMOTHY MICHAEL
Last Name:BALSEIRO
Suffix:
Gender:M
Credentials:LMHC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4091 CYPRESS REACH CT APT 306
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33069-4906
Mailing Address - Country:US
Mailing Address - Phone:786-879-0635
Mailing Address - Fax:
Practice Address - Street 1:1375 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-8304
Practice Address - Country:US
Practice Address - Phone:954-317-9032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-12
Last Update Date:2020-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16973101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health