MEDICARE: CHARLES BALKE PSY.D.

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	103TC0700X	Clinical Psychologist	20042479A	IN

General Provider Information

NPI Number	:	1790113009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES BALKE PSY.D.

Provider Business Mailing Address
First Line	:	7311A W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-6237
Country	:	US
Telephone Number	:	260-471-8033
Fax Number	:	260-471-8107

Provider Business Practice Location Address
First Line	:	7311A W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-6237
Country	:	US
Telephone Number	:	260-471-8033
Fax Number	:	260-471-8107

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

Provider Enumeration Date	:	10/23/2013
Last Update Date	:	07/08/2022

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