Provider Demographics
NPI:1295418713
Name:BALSOM, NICOLE RAE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAE
Last Name:BALSOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37406 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-6051
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 HOLLY LN
Practice Address - Street 2:
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44022-4198
Practice Address - Country:US
Practice Address - Phone:609-558-4007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst