Provider Demographics
NPI:1811668981
Name:BALOUS, JOHNNIE LEWIS JR (MS)
Entity type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:LEWIS
Last Name:BALOUS
Suffix:JR
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 AMBOY DR
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-5202
Mailing Address - Country:US
Mailing Address - Phone:407-202-2996
Mailing Address - Fax:386-316-4695
Practice Address - Street 1:1618 AMBOY DR
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32738-5202
Practice Address - Country:US
Practice Address - Phone:407-202-2996
Practice Address - Fax:386-316-4695
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty