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General NPI Number Information
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NPI Number | 1972906303
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Entity Type | Organization
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Legal Business Name | LAURI BALK PSYD PLLC
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Dates
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Enumeration Date | 09/30/2014
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Last Update Date | 09/30/2014
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Provider Practice Location Address
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Address Line | 1 W SUNBRIDGE DR
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-1825
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Country | US
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Telephone | 479-443-5575
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Fax |
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Provider Business Mailing Address
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Address Line | 1 W SUNBRIDGE DR
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-1825
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Country | US
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Telephone | 479-443-5575
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | LAURI BALK
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Credential | PSYD
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Telephone | 479-443-5575
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 4-01P
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License Number State | AR
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