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General NPI Number Information
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NPI Number | 1407171176
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Entity Type | Organization
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Legal Business Name | A BALANCED LIFE EXPERIENCE
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Dates
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Enumeration Date | 04/06/2010
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Last Update Date | 04/03/2013
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Provider Practice Location Address
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Address Line | 4696 W OVERLAND RD SUITE 118
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City | BOISE
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State | ID
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Zip | 83705-2845
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Country | US
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Telephone | 208-841-3581
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Fax |
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Provider Business Mailing Address
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Address Line | 4696 W OVERLAND RD SUITE 118
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City | BOISE
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State | ID
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Zip | 83705-2845
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Country | US
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Telephone | 208-841-3581
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Fax |
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Authorized Official
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Title or Position | OWNER/COUNSELOR
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Name | ANN J MOORE
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Credential | LCPC, NCC
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Telephone | 208-841-3581
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LPC-3839
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LCPC-3938
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License Number State | ID
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