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General NPI Number Information
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NPI Number | 1396126405
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Entity Type | Organization
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Legal Business Name | BALANCED FAMILY WELLNESS
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Dates
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Enumeration Date | 06/15/2015
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Last Update Date | 06/15/2015
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Provider Practice Location Address
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Address Line | 1200 W 11TH ST SUITE 215
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City | TRAVERSE CITY
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State | MI
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Zip | 49684-3287
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Country | US
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Telephone | 231-313-0773
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Fax |
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Provider Business Mailing Address
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Address Line | 1200 W 11TH ST SUITE 215
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City | TRAVERSE CITY
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State | MI
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Zip | 49684-3287
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Country | US
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Telephone | 231-313-0773
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Fax |
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Authorized Official
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Title or Position | COUNSELOR
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Name | TRISHA SHORT
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Credential | MA, LLPC
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Telephone | 231-313-0773
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 6401014304
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License Number State | MI
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