=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053525808
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALANCE AND WELL BEING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 514 LARKFIELD RD SUITE 4A
-----------------------------------------------------
City | EAST NORTHPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11731-4211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-368-0354
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 514 LARKFIELD RD SUITE 4A
-----------------------------------------------------
City | EAST NORTHPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11731-4211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-368-0354
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. SUSAN LUCIA MONTALBANO
-----------------------------------------------------
Credential | LMHC, CASAC
-----------------------------------------------------
Telephone | 631-368-0354
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 003745
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------