Provider Demographics
NPI:1396126405
Name:BALANCED FAMILY WELLNESS
Entity type:Organization
Organization Name:BALANCED FAMILY WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:TRISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LLPC
Authorized Official - Phone:231-313-0773
Mailing Address - Street 1:1200 W 11TH ST
Mailing Address - Street 2:SUITE 215
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-3287
Mailing Address - Country:US
Mailing Address - Phone:231-313-0773
Mailing Address - Fax:
Practice Address - Street 1:1200 W 11TH ST
Practice Address - Street 2:SUITE 215
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-3287
Practice Address - Country:US
Practice Address - Phone:231-313-0773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014304302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization