Healthcare Provider Details

I. General information

NPI: 1376592790
Provider Name (Legal Business Name): VIJAYKUMAR BALRAJ PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8472 COTTER ST
LEWIS CENTER OH
43035-7139
US

IV. Provider business mailing address

8472 COTTER ST
LEWIS CENTER OH
43035-7139
US

V. Phone/Fax

Practice location:
  • Phone: 614-430-9697
  • Fax: 614-430-9837
Mailing address:
  • Phone: 614-430-9697
  • Fax: 614-430-9837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number5706
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number5706
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: