=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629842364
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEING BALANCED PSYCHOLOGICAL SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2023
-----------------------------------------------------
Last Update Date | 11/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 357 RIVERSIDE DR STE 1000
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37064-5451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-223-4648
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3406 GILLESPIE LN
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38401-8236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LESLIE RUSSELL-MARTIN
-----------------------------------------------------
Credential | PHD LP
-----------------------------------------------------
Telephone | 931-223-4648
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------