Healthcare Provider Details

I. General information

NPI: 1558342006
Provider Name (Legal Business Name): RICHARD MELVIN BALABAN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W KIRKWOOD AVE SUITE 213
BLOOMINGTON IN
47404-6129
US

IV. Provider business mailing address

101 W. KIRKWOOD AVE SUITE 213
BLOOMINGTON IN
47404-6134
US

V. Phone/Fax

Practice location:
  • Phone: 812-332-9200
  • Fax: 812-334-2522
Mailing address:
  • Phone: 812-332-9200
  • Fax: 812-334-2522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20010327
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: