Provider Demographics
NPI:1275337255
Name:BALCORTA, ANDREW CORY
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:CORY
Last Name:BALCORTA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20652 LASSEN ST SPC 62
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-0662
Mailing Address - Country:US
Mailing Address - Phone:818-414-3813
Mailing Address - Fax:
Practice Address - Street 1:14200 RUNNYMEDE ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-1435
Practice Address - Country:US
Practice Address - Phone:818-389-1184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAFBDEA267F171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach