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General NPI Number Information
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NPI Number | 1265939672
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Entity Type | Organization
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Legal Business Name | LIFE WELL BALANCED LLC
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Dates
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Enumeration Date | 04/11/2018
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Last Update Date | 04/11/2018
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Provider Practice Location Address
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Address Line | 103 LINCOLN ST
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City | O FALLON
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State | MO
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Zip | 63366-1603
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Country | US
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Telephone | 636-443-3704
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Fax | 636-294-0530
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Provider Business Mailing Address
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Address Line | 30 OAK VALLEY DR
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City | SAINT PETERS
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State | MO
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Zip | 63376-3721
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Country | US
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Telephone | 636-443-3704
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Fax | 636-294-0530
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Authorized Official
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Title or Position | OWNER
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Name | SARA ANN CARTER
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Credential | LCSW
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Telephone | 636-443-3704
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 2013045632
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License Number State | MO
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