Healthcare Provider Details

I. General information

NPI: 1851790208
Provider Name (Legal Business Name): TONITA BALCOM PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 S MAIN ST
PENNINGTON NJ
08534
US

IV. Provider business mailing address

245 S MAIN ST
PENNINGTON NJ
08534-2837
US

V. Phone/Fax

Practice location:
  • Phone: 609-283-2425
  • Fax:
Mailing address:
  • Phone: 609-283-2425
  • Fax: 609-403-6191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number35S100525100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: