Healthcare Provider Details

I. General information

NPI: 1184429011
Provider Name (Legal Business Name): BALANCED WELLNESS PSYCHOTHERAPY LCSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2025
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E 23RD ST STE 403-2
NEW YORK NY
10010-4511
US

IV. Provider business mailing address

418 BROADWAY STE R
ALBANY NY
12207-2922
US

V. Phone/Fax

Practice location:
  • Phone: 917-524-9667
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. LINNETTA A DE LA CRUZ
Title or Position: CLINICAL DIRECTOR
Credential:
Phone: 917-524-9667