Provider Demographics
NPI:1316197734
Name:BALABANIS, MARK (PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BALABANIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5665 COLLEGE AVE
Mailing Address - Street 2:STE. 240D
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-1625
Mailing Address - Country:US
Mailing Address - Phone:510-457-6601
Mailing Address - Fax:510-380-6687
Practice Address - Street 1:5665 COLLEGE AVE
Practice Address - Street 2:STE. 240D
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1625
Practice Address - Country:US
Practice Address - Phone:510-457-6601
Practice Address - Fax:510-380-6687
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-22
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19438103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist