MEDICARE: BALANSERA THERAPY GROUP

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1912644865
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALANSERA THERAPY GROUP

Provider Business Mailing Address
First Line	:	6501 ARLINGTON EXPRESSWAY
Second Line	:	B105 #2009
City	:	JACKSONVILLE
State	:	FL
Zip	:	32211
Country	:	US
Telephone Number	:	724-622-9155
Fax Number	:

Provider Business Practice Location Address
First Line	:	433 CODY DR
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-4214
Country	:	US
Telephone Number	:	724-622-9155
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MISS SADIE E SCHULTHEIS
Credential	:	LMHC
Telephone Number	:	724-622-9155

Provider Enumeration Date	:	05/12/2022
Last Update Date	:	05/12/2022

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