Provider Demographics
NPI:1649566894
Name:THE LIFE BALANCE CLINIC, BEHAVIORAL HEALTH SERVICE
Entity Type:Organization
Organization Name:THE LIFE BALANCE CLINIC, BEHAVIORAL HEALTH SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-BCD
Authorized Official - Phone:601-831-4402
Mailing Address - Street 1:113 WOODSTONE DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-8319
Mailing Address - Country:US
Mailing Address - Phone:601-831-4402
Mailing Address - Fax:601-262-7226
Practice Address - Street 1:1107 B OPENWOOD ST.
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183
Practice Address - Country:US
Practice Address - Phone:601-831-4402
Practice Address - Fax:601-262-7226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC65821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08000025Medicaid
MS302I801727Medicare UPIN