Provider Demographics
NPI:1750859062
Name:BALOG, ELIZABETH DAKELMAN (OTR/L)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:DAKELMAN
Last Name:BALOG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11690 NEELSVILLE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-4127
Mailing Address - Country:US
Mailing Address - Phone:301-353-0972
Mailing Address - Fax:301-601-0381
Practice Address - Street 1:11690 NEELSVILLE CHURCH RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-4127
Practice Address - Country:US
Practice Address - Phone:301-353-0972
Practice Address - Fax:301-601-0381
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD0062106H00000X
MD03037225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD03037OtherMD STATE BOARD OF OCCUPATIONAL THERY PRACTITIONERS