Provider Demographics
NPI:1194437962
Name:BALANCED MIND PSYCHOTHERAPY, LLC
Entity type:Organization
Organization Name:BALANCED MIND PSYCHOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTICE MANGER AND THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNLAP
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:309-236-0501
Mailing Address - Street 1:2321 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-4756
Mailing Address - Country:US
Mailing Address - Phone:708-831-3782
Mailing Address - Fax:
Practice Address - Street 1:180 N MICHIGAN AVE STE 1510
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7484
Practice Address - Country:US
Practice Address - Phone:708-831-3782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-23
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14410974OtherCOUNCIL FOR AFFORDABLE QUALITY HEALTHCARE