Provider Demographics
NPI:1861817462
Name:BALK, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BALK
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 1:1140 E KIMBERLY RD STE 110
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-1748
Mailing Address - Country:US
Mailing Address - Phone:563-200-3154
Mailing Address - Fax:833-228-5356
Practice Address - Street 1:1140 E KIMBERLY RD UNIT 1B
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-1748
Practice Address - Country:US
Practice Address - Phone:563-200-3154
Practice Address - Fax:833-228-5356
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-19
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001586101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health