MEDICARE: BALANCED COUNSELING AND CONSULTATION

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	101YM0800X	Mental Health Counselor	MH4219	FL
2	101YM0800X	Mental Health Counselor	34003316A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1437387537	OTHER	IN	INDIVIDUAL NPI NUMBER

General Provider Information

NPI Number	:	1891090783
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALANCED COUNSELING AND CONSULTATION

Provider Business Mailing Address
First Line	:	2211 MAPLEWOOD RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46819-1646
Country	:	US
Telephone Number	:	260-437-1248
Fax Number	:	260-478-4727

Provider Business Practice Location Address
First Line	:	2211 MAPLEWOOD RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46819-1646
Country	:	US
Telephone Number	:	260-437-1248
Fax Number	:	260-478-4727

Authorized Official
Title or Position	:	OWNER
Name	:	RITA IRENE POLIVICK
Credential	:	M.S. LCSW, LMHC
Telephone Number	:	260-437-1248

Provider Enumeration Date	:	01/24/2011
Last Update Date	:	01/24/2011

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Directions to “BALANCED COUNSELING AND CONSULTATION ” Practice Location

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