=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235580002
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALANCED BEING COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2016
-----------------------------------------------------
Last Update Date | 06/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1330 POST RD SUITE 4
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06824-6039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-231-3359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1134 VALLEY RD
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06825-1673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-231-3359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/OWNER
-----------------------------------------------------
Name | ALISA L FULVIO
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 203-231-3359
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 008196
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------