Healthcare Provider Details

I. General information

NPI: 1861793184
Provider Name (Legal Business Name): DOUGLAS BALIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2010
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 AVENUE R
BROOKLYN NY
11229-1016
US

IV. Provider business mailing address

1202 AVENUE R
BROOKLYN NY
11229-1016
US

V. Phone/Fax

Practice location:
  • Phone: 718-787-1100
  • Fax: 718-787-9598
Mailing address:
  • Phone: 718-787-1100
  • Fax: 718-787-9598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number078909
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: