Provider Demographics
NPI:1447498282
Name:BALIS, SUSAN A (MSS)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:A
Last Name:BALIS
Suffix:
Gender:F
Credentials:MSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 HAMILTON ST
Mailing Address - Street 2:UNIT 1402
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-4201
Mailing Address - Country:US
Mailing Address - Phone:215-665-9977
Mailing Address - Fax:
Practice Address - Street 1:2542 BROWN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-1811
Practice Address - Country:US
Practice Address - Phone:215-236-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-02
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0128591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000842689Medicare PIN