MEDICARE: DR. LISA RENEE BALICK PHD

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	103TC0700X	Clinical Psychologist	22623	TX

General Provider Information

NPI Number	:	1376608414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA RENEE BALICK PHD

Provider Business Mailing Address
First Line	:	3400 BISSONNET
Second Line	:	282
City	:	HOUSTON
State	:	TX
Zip	:	77005-2100
Country	:	US
Telephone Number	:	713-666-1354
Fax Number	:	713-666-9057

Provider Business Practice Location Address
First Line	:	3400 BISSONNET ST
Second Line	:	STE 282
City	:	HOUSTON
State	:	TX
Zip	:	77005-2100
Country	:	US
Telephone Number	:	713-666-1354
Fax Number	:	713-666-9057

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	03/08/2020

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