Healthcare Provider Details

I. General information

NPI: 1619634177
Provider Name (Legal Business Name): BALANCED LIFE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2021
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 FAIR ST
WALLINGFORD CT
06492-4208
US

IV. Provider business mailing address

2079 KILLINGLY CMNS # 1019
KILLINGLY CT
06241-2190
US

V. Phone/Fax

Practice location:
  • Phone: 860-901-7916
  • Fax:
Mailing address:
  • Phone: 860-901-7916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SAMANTHA NICOLE FORST
Title or Position: SOCIAL WORKER
Credential: LCSW
Phone: 860-901-7916