Provider Demographics
NPI:1386615805
Name:BALES, LARRY (LCSWC)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:BALES
Suffix:
Gender:M
Credentials:LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13218 BROOK LANE DRIVE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-1945
Mailing Address - Country:US
Mailing Address - Phone:301-733-0331
Mailing Address - Fax:301-733-4038
Practice Address - Street 1:13218 BROOK LANE DRIVE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-1945
Practice Address - Country:US
Practice Address - Phone:301-733-0331
Practice Address - Fax:301-733-4038
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD038991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD986965400Medicaid
MDHE02007YMedicare ID - Type Unspecified