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General NPI Number Information
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NPI Number | 1891090783
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Entity Type | Organization
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Legal Business Name | BALANCED COUNSELING AND CONSULTATION
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Dates
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Enumeration Date | 01/24/2011
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Last Update Date | 01/24/2011
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Provider Practice Location Address
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Address Line | 2211 MAPLEWOOD RD
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City | FORT WAYNE
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State | IN
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Zip | 46819-1646
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Country | US
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Telephone | 260-437-1248
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Fax | 260-478-4727
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Provider Business Mailing Address
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Address Line | 2211 MAPLEWOOD RD
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City | FORT WAYNE
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State | IN
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Zip | 46819-1646
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Country | US
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Telephone | 260-437-1248
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Fax | 260-478-4727
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Authorized Official
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Title or Position | OWNER
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Name | RITA IRENE POLIVICK
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Credential | M.S. LCSW, LMHC
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Telephone | 260-437-1248
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH4219
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 34003316A
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License Number State | IN
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