=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740919653
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALANCE THERAPY SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2022
-----------------------------------------------------
Last Update Date | 06/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1224 MILL STREET BLDG. B SUITE 113
-----------------------------------------------------
City | EAST BERLIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06023-1140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-748-9443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1224 MILL ST STE 113
-----------------------------------------------------
City | EAST BERLIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06023-1159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-748-9443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/FOUNDER
-----------------------------------------------------
Name | JASON P TARTT
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 860-748-9443
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------