Provider Demographics
NPI:1073608360
Name:BALOG, SHEILA A (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHEILA
Middle Name:A
Last Name:BALOG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:82 SAMOSET TRL
Mailing Address - Street 2:
Mailing Address - City:EAST BOOTHBAY
Mailing Address - State:ME
Mailing Address - Zip Code:04544-6252
Mailing Address - Country:US
Mailing Address - Phone:207-749-8732
Mailing Address - Fax:678-432-1397
Practice Address - Street 1:63 ELM ST STE A
Practice Address - Street 2:
Practice Address - City:TOPSHAM
Practice Address - State:ME
Practice Address - Zip Code:04086-1424
Practice Address - Country:US
Practice Address - Phone:207-749-8732
Practice Address - Fax:678-432-1397
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1287103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00857073CMedicaid
ME435477000Medicaid