Healthcare Provider Details

I. General information

NPI: 1760705933
Provider Name (Legal Business Name): SUSAN BALKMAN LPC, LADAC, CPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 HARKLE RD
SANTA FE NM
87505-4784
US

IV. Provider business mailing address

PO BOX 29503 15 ENMEDIO PLACE
SANTA FE NM
87592-9503
US

V. Phone/Fax

Practice location:
  • Phone: 505-795-9027
  • Fax:
Mailing address:
  • Phone: 505-795-9027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3626
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1131
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: