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General NPI Number Information
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NPI Number | 1811244858
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Entity Type | Organization
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Legal Business Name | LIFE BALANCE CLINIC LLC
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Dates
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Enumeration Date | 08/09/2012
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Last Update Date | 08/07/2018
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Provider Practice Location Address
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Address Line | 1107 OPENWOOD ST
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City | VICKSBURG
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State | MS
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Zip | 39183
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Country | US
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Telephone | 601-831-4402
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Fax | 601-206-0672
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Provider Business Mailing Address
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Address Line | 113 WOODSTONE DR
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City | VICKSBURG
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State | MS
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Zip | 39183-8319
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Country | US
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Telephone | 601-831-4402
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Fax | 601-206-0672
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | DR. ANNETTE BRYANT
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Credential | PHD-ABD, LCSW
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Telephone | 601-831-4402
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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 | C6582
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License Number State | MS
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