Provider Demographics
NPI:1811358278
Name:BALALAOS, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BALALAOS
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 1:8 SHIRE DR
Mailing Address - Street 2:
Mailing Address - City:GREENLAWN
Mailing Address - State:NY
Mailing Address - Zip Code:11740-2618
Mailing Address - Country:US
Mailing Address - Phone:631-682-7296
Mailing Address - Fax:631-239-5004
Practice Address - Street 1:8 SHIRE DR
Practice Address - Street 2:
Practice Address - City:GREENLAWN
Practice Address - State:NY
Practice Address - Zip Code:11740-2618
Practice Address - Country:US
Practice Address - Phone:631-682-7296
Practice Address - Fax:631-239-5004
Is Sole Proprietor?:No
Enumeration Date:2016-03-14
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008568-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health