Provider Demographics
NPI:1083153837
Name:A BALANCED LIFE: INDIVIDUAL, FAMILY AND CHILD THERAPY, INC
Entity Type:Organization
Organization Name:A BALANCED LIFE: INDIVIDUAL, FAMILY AND CHILD THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:530-544-1748
Mailing Address - Street 1:PO BOX 7152
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96158-0152
Mailing Address - Country:US
Mailing Address - Phone:530-544-1748
Mailing Address - Fax:530-544-1728
Practice Address - Street 1:2100 ELOISE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-4306
Practice Address - Country:US
Practice Address - Phone:530-544-1748
Practice Address - Fax:530-544-1728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW24256101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1609150853Medicare NSC