Provider Demographics
NPI:1518030790
Name:BALKENBUSH, NANCY ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:ANN
Last Name:BALKENBUSH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1512
Mailing Address - Street 2:
Mailing Address - City:TWAIN HARTE
Mailing Address - State:CA
Mailing Address - Zip Code:95383-1512
Mailing Address - Country:US
Mailing Address - Phone:209-533-0548
Mailing Address - Fax:
Practice Address - Street 1:115 BRADFORD ST
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-4956
Practice Address - Country:US
Practice Address - Phone:209-533-0548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS9654101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ21253ZMedicare ID - Type Unspecified