Healthcare Provider Details

I. General information

NPI: 1912644865
Provider Name (Legal Business Name): BALANSERA THERAPY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 CODY DR
ORANGE PARK FL
32073-4214
US

IV. Provider business mailing address

6501 ARLINGTON EXPRESSWAY B105 #2009
JACKSONVILLE FL
32211
US

V. Phone/Fax

Practice location:
  • Phone: 724-622-9155
  • Fax:
Mailing address:
  • Phone: 724-622-9155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MISS SADIE E SCHULTHEIS
Title or Position: OWNER
Credential: LMHC
Phone: 724-622-9155