Provider Demographics
NPI:1780867689
Name:BALS, LISA M (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:BALS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 COMMERCIAL ST
Mailing Address - Street 2:SUITE 404
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4613
Mailing Address - Country:US
Mailing Address - Phone:207-450-9558
Mailing Address - Fax:207-699-5757
Practice Address - Street 1:225 COMMERCIAL ST
Practice Address - Street 2:SUITE 404
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4613
Practice Address - Country:US
Practice Address - Phone:207-450-9558
Practice Address - Fax:207-699-5757
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-13
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC11303101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health