Provider Demographics
NPI:1104955418
Name:BALCERZAK, RITAMARIE RISLEY (MA)
Entity type:Individual
Prefix:MS
First Name:RITAMARIE
Middle Name:RISLEY
Last Name:BALCERZAK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2186 3RD ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3263
Mailing Address - Country:US
Mailing Address - Phone:651-227-8880
Mailing Address - Fax:651-227-8908
Practice Address - Street 1:2186 3RD ST
Practice Address - Street 2:SUITE 105
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3263
Practice Address - Country:US
Practice Address - Phone:651-227-8880
Practice Address - Fax:651-227-8908
Is Sole Proprietor?:No
Enumeration Date:2007-03-04
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1726103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN546547800Medicaid
MN620000141Medicare ID - Type Unspecified