Provider Demographics
NPI:1427647262
Name:BALCOM, DREW RANDALL
Entity type:Individual
Prefix:
First Name:DREW
Middle Name:RANDALL
Last Name:BALCOM
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:PO BOX 1501
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92822-1501
Mailing Address - Country:US
Mailing Address - Phone:714-519-6461
Mailing Address - Fax:
Practice Address - Street 1:4019 WESTERLY PL STE 102
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2333
Practice Address - Country:US
Practice Address - Phone:714-519-6461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-15
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94028862103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist