Provider Demographics
NPI:1104970201
Name:BALK, JILL A (LCSW)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:A
Last Name:BALK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 EDGEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-1306
Mailing Address - Country:US
Mailing Address - Phone:631-385-9855
Mailing Address - Fax:631-351-3533
Practice Address - Street 1:15 EDGEWOOD PL
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-1306
Practice Address - Country:US
Practice Address - Phone:631-385-9855
Practice Address - Fax:631-351-3533
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0236291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN12481Medicare ID - Type Unspecified