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General NPI Number Information
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NPI Number | 1508004664
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Entity Type | Organization
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Legal Business Name | THE BALANCED LIFESTYLE GRP., LLC
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Dates
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Enumeration Date | 01/28/2009
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Last Update Date | 01/28/2009
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Provider Practice Location Address
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Address Line | 1721 DANA AVE
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City | CINCINNATI
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State | OH
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Zip | 45207-1138
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Country | US
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Telephone | 513-731-4004
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Fax | 513-731-4005
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Provider Business Mailing Address
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Address Line | 1721 DANA AVE
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City | CINCINNATI
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State | OH
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Zip | 45207-1138
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Country | US
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Telephone | 513-731-4004
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Fax | 513-731-4005
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Authorized Official
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Title or Position | PSYCHOTHERAPIST
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Name | MS. CONSTANCE L. BATES
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Credential | LISW-S
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Telephone | 513-731-4909
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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 | I 0600003
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License Number State | OH
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