Healthcare Provider Details

I. General information

NPI: 1467487371
Provider Name (Legal Business Name): ELLEN BALZE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 BALA AVE
BALA CYNWYD PA
19004-3201
US

IV. Provider business mailing address

11 BALA AVE
BALA CYNWYD PA
19004-3201
US

V. Phone/Fax

Practice location:
  • Phone: 215-519-4056
  • Fax:
Mailing address:
  • Phone: 215-519-4056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS009029-L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS009029-L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberPS009029-L
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberPS009029-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: