Provider Demographics
NPI:1528546850
Name:BALOG, AMANDA (MA, EDS)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BALOG
Suffix:
Gender:F
Credentials:MA, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 FARMINGTON DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-5548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:480 FARMINGTON DR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-5548
Practice Address - Country:US
Practice Address - Phone:925-513-6430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool