Provider Demographics
NPI:1952651895
Name:CHILDREN IN BALANCE PSYCHOLOGICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:CHILDREN IN BALANCE PSYCHOLOGICAL ASSOCIATES LLC
Other - Org Name:CENTER FOR SELF CARE CSC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/EXECUTIVE DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURQUIN
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:508-962-7364
Mailing Address - Street 1:P.O. BOX 577
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:MA
Mailing Address - Zip Code:02726
Mailing Address - Country:US
Mailing Address - Phone:508-962-7364
Mailing Address - Fax:401-619-7766
Practice Address - Street 1:575 E MAIN RD
Practice Address - Street 2:4
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-5528
Practice Address - Country:US
Practice Address - Phone:508-962-7364
Practice Address - Fax:401-619-7766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00547101YM0800X
MA6722101YM0800X
MA7566101YM0800X, 251S00000X
RI7566101YM0800X
RICSW017241041C0700X
RI024721041C0700X
RIMHC00502251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1669631487OtherINDIVIDUAL NPI 1669631487
RIBH90286Medicaid