MEDICARE: MRS. CYNTHIA DEWATERS BALOG LCPC LCADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	LCA362	MD
2	101YP2500X	Professional Counselor	LC1289	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	461922374	OTHER	MD	CIGNA
2	676829	OTHER	MD	BEACON HEALTH OPTIONS
3	RS830034	OTHER		CAREFIRST GHMSI
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	62464101	OTHER		CAREFIRST MD

General Provider Information

NPI Number	:	1730271792
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CYNTHIA DEWATERS BALOG LCPC LCADC

Provider Business Mailing Address
First Line	:	3314 PAPER MILL RD STE 100
Second Line	:
City	:	PHOENIX
State	:	MD
Zip	:	21131-1446
Country	:	US
Telephone Number	:	410-802-4049
Fax Number	:	866-561-6670

Provider Business Practice Location Address
First Line	:	3314 PAPER MILL RD STE 100
Second Line	:
City	:	PHOENIX
State	:	MD
Zip	:	21131-1446
Country	:	US
Telephone Number	:	410-802-4049
Fax Number	:	866-561-6670

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	10/13/2021

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