Healthcare Provider Details

I. General information

NPI: 1235548793
Provider Name (Legal Business Name): JAIME SAMANTHA BALIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2014
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 BOUNTY LN
JERICHO NY
11753-2210
US

IV. Provider business mailing address

245 E 63RD ST APT 32G
NEW YORK NY
10065-7432
US

V. Phone/Fax

Practice location:
  • Phone: 516-312-5739
  • Fax:
Mailing address:
  • Phone: 516-312-5739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number086530-01
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: