Provider Demographics
NPI:1467232660
Name:PH BALANCE THERAPEUTICS
Entity Type:Organization
Organization Name:PH BALANCE THERAPEUTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO & FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:PEREA-HICKAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, BCBA, MFTC, ADD
Authorized Official - Phone:720-410-4529
Mailing Address - Street 1:954 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-5424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:525 3RD AVE STE 211C
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-5859
Practice Address - Country:US
Practice Address - Phone:720-410-4529
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty