MEDICARE: BALANCED MIND LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1134909922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALANCED MIND LCSW

Provider Business Mailing Address
First Line	:	1125 45TH AVE APT 3B
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-5176
Country	:	US
Telephone Number	:	818-642-1349
Fax Number	:

Provider Business Practice Location Address
First Line	:	1125 45TH AVE APT 3B
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-5176
Country	:	US
Telephone Number	:	818-642-1349
Fax Number	:

Authorized Official
Title or Position	:	CLINICIAN
Name	:	GRACE HIGA
Credential	:	LCSW
Telephone Number	:	818-642-1349

Provider Enumeration Date	:	09/29/2023
Last Update Date	:	09/29/2023

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