Provider Demographics
NPI:1801056775
Name:BALCH, DESTRY L (LPC, NCC)
Entity type:Individual
Prefix:MR
First Name:DESTRY
Middle Name:L
Last Name:BALCH
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 197
Mailing Address - Street 2:
Mailing Address - City:MINERSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84752
Mailing Address - Country:US
Mailing Address - Phone:435-590-5120
Mailing Address - Fax:
Practice Address - Street 1:580 N MAIN PAROWAN
Practice Address - Street 2:
Practice Address - City:MINERSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84752
Practice Address - Country:US
Practice Address - Phone:435-590-5120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
UT101YP2500X
UT5336089-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional