MEDICARE: THE BALANCED LIFESTYLE GRP., LLC

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	1041C0700X	Clinical Social Worker	I 0600003	OH

General Provider Information

NPI Number	:	1508004664
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE BALANCED LIFESTYLE GRP., LLC

Provider Business Mailing Address
First Line	:	1721 DANA AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45207-1138
Country	:	US
Telephone Number	:	513-731-4004
Fax Number	:	513-731-4005

Provider Business Practice Location Address
First Line	:	1721 DANA AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45207-1138
Country	:	US
Telephone Number	:	513-731-4004
Fax Number	:	513-731-4005

Authorized Official
Title or Position	:	PSYCHOTHERAPIST
Name	:	MS. CONSTANCE L. BATES
Credential	:	LISW-S
Telephone Number	:	513-731-4909

Provider Enumeration Date	:	01/28/2009
Last Update Date	:	01/28/2009

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