Provider Demographics
NPI:1063172344
Name:BALCOM, BRIANNA LEE
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:LEE
Last Name:BALCOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16201 E INDIANA AVE STE 3400
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-2830
Mailing Address - Country:US
Mailing Address - Phone:509-900-3669
Mailing Address - Fax:
Practice Address - Street 1:16201 E INDIANA AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-2830
Practice Address - Country:US
Practice Address - Phone:509-900-3669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61034853106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician