Provider Demographics
NPI:1477565240
Name:BALCHUNAS, JOHN W (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:BALCHUNAS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-2541
Mailing Address - Country:US
Mailing Address - Phone:270-782-1116
Mailing Address - Fax:270-782-9108
Practice Address - Street 1:1215 HIGH ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2541
Practice Address - Country:US
Practice Address - Phone:270-782-1116
Practice Address - Fax:270-782-9108
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0743103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid