Provider Demographics
NPI:1174030902
Name:BALSAMO, ANNA (LPCC)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:BALSAMO
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:
Other - Last Name:INGRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1726 AGUA FRIA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-0980
Mailing Address - Country:US
Mailing Address - Phone:207-216-3272
Mailing Address - Fax:
Practice Address - Street 1:16A TAYEH HUU U
Practice Address - Street 2:
Practice Address - City:NAMBE PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-930-2784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0212661101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional