MEDICARE: BALANCED THERAPY AND WELLNESS, INC

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	225X00000X	Occupational Therapist	31003490A	IN
2	225100000X	Physical Therapist	05007382A	IN

General Provider Information

NPI Number	:	1871010645
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALANCED THERAPY AND WELLNESS, INC

Provider Business Mailing Address
First Line	:	PO BOX 1031
Second Line	:
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46361-8231
Country	:	US
Telephone Number	:	708-567-3891
Fax Number	:	219-879-5416

Provider Business Practice Location Address
First Line	:	5271 N JOHNSON RD
Second Line	:
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-9377
Country	:	US
Telephone Number	:	708-567-3891
Fax Number	:	219-879-5416

Authorized Official
Title or Position	:	CEO/PHYSICAL THERAPIST
Name	:	DR. DAWN D BANCSI
Credential	:	DPT
Telephone Number	:	708-567-3891

Provider Enumeration Date	:	08/23/2017
Last Update Date	:	08/23/2017

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