Provider Demographics
NPI:1700243912
Name:BALES, JOSHUA MORRIS (MA, MDIV)
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:MORRIS
Last Name:BALES
Suffix:
Gender:M
Credentials:MA, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:668 N ORLANDO AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4473
Mailing Address - Country:US
Mailing Address - Phone:407-951-8829
Mailing Address - Fax:
Practice Address - Street 1:668 N ORLANDO AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4473
Practice Address - Country:US
Practice Address - Phone:407-951-8829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 12754101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIMH 12754OtherDEPARTMENT OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE