Provider Demographics
NPI:1235548793
Name:BALIS, JAIME SAMANTHA (LCSW)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:SAMANTHA
Last Name:BALIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 E 63RD ST APT 32G
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-7432
Mailing Address - Country:US
Mailing Address - Phone:516-312-5739
Mailing Address - Fax:
Practice Address - Street 1:82 BOUNTY LN
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-2210
Practice Address - Country:US
Practice Address - Phone:516-312-5739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-10
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY086530-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical