Provider Demographics
NPI:1265619027
Name:BALSAMO, SUSAN META (LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:META
Last Name:BALSAMO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10376 PALMGREN LANE
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34608
Mailing Address - Country:US
Mailing Address - Phone:352-650-1573
Mailing Address - Fax:
Practice Address - Street 1:1265 KASS CIR
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606-4308
Practice Address - Country:US
Practice Address - Phone:352-686-3188
Practice Address - Fax:352-686-9394
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-23
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW83931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000017900Medicaid
FLSW8393OtherLCSW
FLBR614ZMedicare PIN