Provider Demographics
NPI:1790113009
Name:BALKE, CHARLES (PSYD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BALKE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7311A W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6237
Mailing Address - Country:US
Mailing Address - Phone:260-471-8033
Mailing Address - Fax:260-471-8107
Practice Address - Street 1:7311A W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6237
Practice Address - Country:US
Practice Address - Phone:260-471-8033
Practice Address - Fax:260-471-8107
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-23
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042479A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical