Healthcare Provider Details

I. General information

NPI: 1982216099
Provider Name (Legal Business Name): WELL BALANCED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E JOPPA RD STE 203
TOWSON MD
21286-3107
US

IV. Provider business mailing address

6504 COPPER RIDGE DR APT 101
BALTIMORE MD
21209-2357
US

V. Phone/Fax

Practice location:
  • Phone: 443-304-8853
  • Fax:
Mailing address:
  • Phone: 610-453-1036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. ZAKIA V JOHNSON
Title or Position: THERAPIST
Credential: LCPC
Phone: 443-304-8853