Healthcare Provider Details

I. General information

NPI: 1851744403
Provider Name (Legal Business Name): SAMUEL EDWARD BALLA LISW-S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 N. SANDUSKY ST
DELAWARE OH
43015
US

IV. Provider business mailing address

1791 ALUM CREEK DR
COLUMBUS OH
43207-1708
US

V. Phone/Fax

Practice location:
  • Phone: 740-203-3800
  • Fax: 740-203-3799
Mailing address:
  • Phone: 614-445-8131
  • Fax: 614-827-8380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI1500113SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: