Provider Demographics
NPI:1700657939
Name:BALZER, BRANDY
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:BALZER
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 1:6165 ALLMONDSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-3336
Mailing Address - Country:US
Mailing Address - Phone:757-645-8041
Mailing Address - Fax:
Practice Address - Street 1:6165 ALLMONDSVILLE RD
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-3336
Practice Address - Country:US
Practice Address - Phone:757-645-8041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701013201101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVA0297G669Medicaid