Healthcare Provider Details

I. General information

NPI: 1366981524
Provider Name (Legal Business Name): DESIREE BALCONI LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2017
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44070 W 12 MILE RD SUITE #200
NOVI MI
48377-2648
US

IV. Provider business mailing address

7 PARKSIDE BLVD
PORT WENTWORTH GA
31407-3343
US

V. Phone/Fax

Practice location:
  • Phone: 248-773-8440
  • Fax: 248-773-8441
Mailing address:
  • Phone: 906-361-9066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401015905
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: