MEDICARE: WELL BALANE COUNSELING SERVICES

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	13031560	SD
2	101YM0800X	Mental Health Counselor	LPC-MH20198	SD

General Provider Information

NPI Number	:	1689193344
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELL BALANE COUNSELING SERVICES

Provider Business Mailing Address
First Line	:	5201 S BAHNSON AVE
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57108-2594
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 S REID ST STE 307
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57103-7045
Country	:	US
Telephone Number	:	605-212-6315
Fax Number	:

Authorized Official
Title or Position	:	OWNER/COUNSELOR
Name	:	ELIZABETH CLAYBORNE-MOELLER
Credential	:
Telephone Number	:	605-212-6315

Provider Enumeration Date	:	09/13/2017
Last Update Date	:	09/13/2017

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