Healthcare Provider Details

I. General information

NPI: 1679903199
Provider Name (Legal Business Name): STACEY BALLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2013
Last Update Date: 01/02/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 W. MAIN ST.
KUNA ID
83634
US

IV. Provider business mailing address

PO BOX 203
KUNA ID
83634-0203
US

V. Phone/Fax

Practice location:
  • Phone: 702-582-2130
  • Fax:
Mailing address:
  • Phone: 702-582-2130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number40516
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: