Provider Demographics
NPI:1558342006
Name:BALABAN, RICHARD MELVIN (PHD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:MELVIN
Last Name:BALABAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W. KIRKWOOD AVE
Mailing Address - Street 2:SUITE 213
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-6134
Mailing Address - Country:US
Mailing Address - Phone:812-332-9200
Mailing Address - Fax:812-334-2522
Practice Address - Street 1:101 W KIRKWOOD AVE
Practice Address - Street 2:SUITE 213
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-6129
Practice Address - Country:US
Practice Address - Phone:812-332-9200
Practice Address - Fax:812-334-2522
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010327103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000235771OtherANTHEM
IN547360Medicare ID - Type Unspecified