Provider Demographics
NPI:1972906303
Name:LAURI BALK PSYD PLLC
Entity Type:Organization
Organization Name:LAURI BALK PSYD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURI
Authorized Official - Middle Name:
Authorized Official - Last Name:BALK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:479-443-5575
Mailing Address - Street 1:1 W SUNBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-1825
Mailing Address - Country:US
Mailing Address - Phone:479-443-5575
Mailing Address - Fax:
Practice Address - Street 1:1 W SUNBRIDGE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1825
Practice Address - Country:US
Practice Address - Phone:479-443-5575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4-01P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty