Provider Demographics
NPI:1073274627
Name:CREATE YOUR BALANCE MENTAL HEALTH COUNSELING
Entity Type:Organization
Organization Name:CREATE YOUR BALANCE MENTAL HEALTH COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JILLIAN
Authorized Official - Middle Name:LAUREN
Authorized Official - Last Name:DECOURSEY
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:917-239-5734
Mailing Address - Street 1:25410 NORTHERN BLVD STE 211
Mailing Address - Street 2:
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-1415
Mailing Address - Country:US
Mailing Address - Phone:917-239-5734
Mailing Address - Fax:718-819-1148
Practice Address - Street 1:25410 NORTHERN BLVD STE 211
Practice Address - Street 2:
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362-1415
Practice Address - Country:US
Practice Address - Phone:917-239-5734
Practice Address - Fax:718-819-1148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health