Healthcare Provider Details

I. General information

NPI: 1619725876
Provider Name (Legal Business Name): MELINDA BALK CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

803 S LANE ST
SEATTLE WA
98104-3044
US

IV. Provider business mailing address

803 S LANE ST
SEATTLE WA
98104-3044
US

V. Phone/Fax

Practice location:
  • Phone: 206-521-4116
  • Fax:
Mailing address:
  • Phone: 206-521-4116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License NumberRE60760119
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: