Provider Demographics
NPI:1164776431
Name:BALSAMO, BONNIE LYNN (LICSW)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:LYNN
Last Name:BALSAMO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:NH
Mailing Address - Zip Code:03584-3508
Mailing Address - Country:US
Mailing Address - Phone:603-788-5029
Mailing Address - Fax:603-788-5607
Practice Address - Street 1:141 CORLISS LN
Practice Address - Street 2:
Practice Address - City:COLEBROOK
Practice Address - State:NH
Practice Address - Zip Code:03576-3206
Practice Address - Country:US
Practice Address - Phone:603-788-5075
Practice Address - Fax:037-885-2856
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.01272771041C0700X
WI89701041C0700X
MA1189841041C0700X
NH20091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3135038Medicaid
VT6710489Medicaid