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General NPI Number Information
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NPI Number | 1467232660
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Entity Type | Organization
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Legal Business Name | PH BALANCE THERAPEUTICS
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Dates
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Enumeration Date | 10/04/2023
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Last Update Date | 10/04/2023
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Provider Practice Location Address
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Address Line | 525 3RD AVE STE 211C
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City | LONGMONT
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State | CO
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Zip | 80501-5859
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Country | US
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Telephone | 720-410-4529
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Fax |
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Provider Business Mailing Address
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Address Line | 954 5TH AVE
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City | LONGMONT
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State | CO
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Zip | 80501-5424
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO & FOUNDER
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Name | DR. BRANDON ARTHUR PEREA-HICKAM
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Credential | PHD, BCBA, MFTC, ADD
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Telephone | 720-410-4529
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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