Provider Demographics
NPI:1811026123
Name:PSYCHOLOGICAL&BEHAVIORALCONSULTANTSPA
Entity Type:Organization
Organization Name:PSYCHOLOGICAL&BEHAVIORALCONSULTANTSPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:W
Authorized Official - Middle Name:S
Authorized Official - Last Name:BALCERZAK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:651-227-8880
Mailing Address - Street 1:2186 3RD ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3263
Mailing Address - Country:US
Mailing Address - Phone:651-227-8880
Mailing Address - Fax:651-227-8908
Practice Address - Street 1:2186 3RD ST
Practice Address - Street 2:SUITE 105
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3263
Practice Address - Country:US
Practice Address - Phone:651-227-8880
Practice Address - Fax:651-227-8908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-04
Last Update Date:2013-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN998518200Medicaid
MNC04211Medicare ID - Type Unspecified