MEDICARE: CREATING BALANCE 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	3946-125	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588073860
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATING BALANCE LLC

Provider Business Mailing Address
First Line	:	385 WILLIAMSTOWNE
Second Line	:	SUITE 105
City	:	DELAFIELD
State	:	WI
Zip	:	53018-2323
Country	:	US
Telephone Number	:	262-894-3540
Fax Number	:	262-303-4765

Provider Business Practice Location Address
First Line	:	385 WILLIAMSTOWNE
Second Line	:	SUITE 105
City	:	DELAFIELD
State	:	WI
Zip	:	53018-2323
Country	:	US
Telephone Number	:	262-894-3540
Fax Number	:	262-303-4765

Authorized Official
Title or Position	:	PSYCHOTHERAPIST/SOLEPROPRIETOR
Name	:	MAUREEN POHLE
Credential	:	LPC
Telephone Number	:	262-894-3540

Provider Enumeration Date	:	08/12/2014
Last Update Date	:	09/28/2015

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