Provider Demographics
NPI:1508004664
Name:THE BALANCED LIFESTYLE GRP., LLC
Entity Type:Organization
Organization Name:THE BALANCED LIFESTYLE GRP., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-S
Authorized Official - Phone:513-731-4909
Mailing Address - Street 1:1721 DANA AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45207-1138
Mailing Address - Country:US
Mailing Address - Phone:513-731-4004
Mailing Address - Fax:513-731-4005
Practice Address - Street 1:1721 DANA AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45207-1138
Practice Address - Country:US
Practice Address - Phone:513-731-4004
Practice Address - Fax:513-731-4005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-28
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 06000031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty