Provider Demographics
NPI:1922169002
Name:BALEN, MARK LANE (MFT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LANE
Last Name:BALEN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2368 STEARNS RD
Mailing Address - Street 2:
Mailing Address - City:PARADISE
Mailing Address - State:CA
Mailing Address - Zip Code:95969
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 COHASSET RD
Practice Address - Street 2:SUITE 25
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-2260
Practice Address - Country:US
Practice Address - Phone:530-879-2456
Practice Address - Fax:530-879-3932
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT17694106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFT17694OtherBBSE