Provider Demographics
NPI:1366960767
Name:BALLES, MICHAEL (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BALLES
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:876 LATTINTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:NY
Mailing Address - Zip Code:12547-5232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 SEMINARY HILL RD
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512-1921
Practice Address - Country:US
Practice Address - Phone:845-225-3400
Practice Address - Fax:845-704-6182
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101296104100000X
NY0935301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420795Medicaid