Provider Demographics
NPI:1336687573
Name:BALKUN, LUKE
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:
Last Name:BALKUN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 SE 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-1968
Mailing Address - Country:US
Mailing Address - Phone:401-212-7015
Mailing Address - Fax:
Practice Address - Street 1:2262 WESTWOOD RD
Practice Address - Street 2:
Practice Address - City:N FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33917-2536
Practice Address - Country:US
Practice Address - Phone:401-212-7015
Practice Address - Fax:407-960-3009
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician