Healthcare Provider Details

I. General information

NPI: 1215401401
Provider Name (Legal Business Name): JOHN WINTERS BALEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 WESTERN BLVD
RALEIGH NC
27606-2148
US

IV. Provider business mailing address

250 S ESTES DR APT 83
CHAPEL HILL NC
27514-7000
US

V. Phone/Fax

Practice location:
  • Phone: 919-743-4018
  • Fax:
Mailing address:
  • Phone: 828-208-0277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5073
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number5073
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number5073
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-20592
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number5073
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number5073
License Number StateNC
# 7
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number5073
License Number StateNC
# 8
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number5073
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: