Provider Demographics
NPI:1265740096
Name:BALANCE FOR HEALTHY LIVING, PC
Entity type:Organization
Organization Name:BALANCE FOR HEALTHY LIVING, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIRZAH
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-407-9232
Mailing Address - Street 1:6129 NE SKIDMORE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-2227
Mailing Address - Country:US
Mailing Address - Phone:503-407-9232
Mailing Address - Fax:
Practice Address - Street 1:6129 NE SKIDMORE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97218-2227
Practice Address - Country:US
Practice Address - Phone:503-407-9232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1780101Y00000X, 101YM0800X, 101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500601179Medicaid
OR11607801OtherCAQH