Healthcare Provider Details

I. General information

NPI: 1003678624
Provider Name (Legal Business Name): LISA LYNN BALDERSTONE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5331 COMMERCIAL WAY STE 209
SPRING HILL FL
34606-1426
US

IV. Provider business mailing address

3986 BRAMBLEWOOD LOOP
SPRING HILL FL
34609-0664
US

V. Phone/Fax

Practice location:
  • Phone: 352-515-0000
  • Fax: 352-556-5729
Mailing address:
  • Phone: 989-482-9858
  • Fax: 352-556-5729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberISW17277
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: