Provider Demographics
NPI:1366981524
Name:BALCONI, DESIREE (LLPC)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:BALCONI
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 PARKSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT WENTWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-3343
Mailing Address - Country:US
Mailing Address - Phone:906-361-9066
Mailing Address - Fax:
Practice Address - Street 1:44070 W 12 MILE RD
Practice Address - Street 2:SUITE #200
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2648
Practice Address - Country:US
Practice Address - Phone:248-773-8440
Practice Address - Fax:248-773-8441
Is Sole Proprietor?:No
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015905101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional