Provider Demographics
NPI:1154156776
Name:MY RESTORED BALANCE LLC
Entity type:Organization
Organization Name:MY RESTORED BALANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHMM
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:314-766-7065
Mailing Address - Street 1:202 N DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-1228
Mailing Address - Country:US
Mailing Address - Phone:573-604-4167
Mailing Address - Fax:866-811-7475
Practice Address - Street 1:202 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-1228
Practice Address - Country:US
Practice Address - Phone:573-604-4167
Practice Address - Fax:866-811-7475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-04
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty