Provider Demographics
NPI:1578059036
Name:BALCOME, JOAN L
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:L
Last Name:BALCOME
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 4TH ST E STE 301
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-1771
Mailing Address - Country:US
Mailing Address - Phone:651-413-9938
Mailing Address - Fax:651-344-0515
Practice Address - Street 1:1001 14TH ST NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-2590
Practice Address - Country:US
Practice Address - Phone:507-534-2668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MN4119106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health