Provider Demographics
NPI:1912480799
Name:BALCOM, DANIELLE (LICSW)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:BALCOM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:ALLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-1318
Mailing Address - Country:US
Mailing Address - Phone:617-553-5776
Mailing Address - Fax:617-232-2165
Practice Address - Street 1:250 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-1318
Practice Address - Country:US
Practice Address - Phone:617-553-5776
Practice Address - Fax:617-232-2165
Is Sole Proprietor?:No
Enumeration Date:2018-09-08
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1200841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical