=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508641309
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALANCED LIFE BEHAVIORAL HEALTH AND COUNSELING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2023
-----------------------------------------------------
Last Update Date | 08/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 516 N ROLLING RD STE 301
-----------------------------------------------------
City | CATONSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21228-4133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-791-6150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10207 CHAUTAUQUA AVE
-----------------------------------------------------
City | LANHAM
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20706-2038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-791-6150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER OF ENTITY
-----------------------------------------------------
Name | BENNETH EKWE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 240-791-6150
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------