Provider Demographics
NPI:1457411654
Name:BALICH, ROBERT ELI (MS)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ELI
Last Name:BALICH
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1263 N 15TH ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-2343
Mailing Address - Country:US
Mailing Address - Phone:307-745-8915
Mailing Address - Fax:307-745-8761
Practice Address - Street 1:1770 25TH AVE STE 206
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4949
Practice Address - Country:US
Practice Address - Phone:307-745-8915
Practice Address - Fax:307-745-8761
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1335101YP2500X
CO0015268101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional