MEDICARE: A BALANCED LIFE: INDIVIDUAL, FAMILY & CHILD THERAPY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	50196	CA
2	106H00000X	Marriage & Family Therapist	50196	CA

General Provider Information

NPI Number	:	1013297837
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A BALANCED LIFE: INDIVIDUAL, FAMILY & CHILD THERAPY, INC.

Provider Business Mailing Address
First Line	:	2100 ELOISE AVE
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-4306
Country	:	US
Telephone Number	:	530-544-1748
Fax Number	:	530-544-1728

Provider Business Practice Location Address
First Line	:	2100 ELOISE AVE
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-4306
Country	:	US
Telephone Number	:	530-544-1748
Fax Number	:	530-544-1728

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MS. LINDSAY I SIMON
Credential	:	LMFT
Telephone Number	:	530-544-1748

Provider Enumeration Date	:	08/24/2011
Last Update Date	:	07/21/2022

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