=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124485495
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELISABETH ANNE BALCOM M.A.,CCC/SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2016
-----------------------------------------------------
Last Update Date | 12/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12778 ROAD 37 1/2
-----------------------------------------------------
City | MADERA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93636-8757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-430-8239
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4560 SE INTERNATIONAL WAY STE 100
-----------------------------------------------------
City | MILWAUKIE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97222-4628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SP16633
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------