Provider Demographics
NPI:1952648107
Name:CBT CENTER FOR BALANCED LIVING, PLLC
Entity Type:Organization
Organization Name:CBT CENTER FOR BALANCED LIVING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-729-4228
Mailing Address - Street 1:132 JOE KNOX AVE
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9202
Mailing Address - Country:US
Mailing Address - Phone:704-729-4228
Mailing Address - Fax:
Practice Address - Street 1:136 MUSSELL LN
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-3707
Practice Address - Country:US
Practice Address - Phone:704-230-7998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0058721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007471Medicaid
NC6007471Medicaid