Provider Demographics
NPI:1750090734
Name:BALSAMO, MELANIE
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:BALSAMO
Suffix:
Gender:F
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 1823
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71294-1823
Mailing Address - Country:US
Mailing Address - Phone:318-588-8908
Mailing Address - Fax:318-588-8909
Practice Address - Street 1:2808 KILPATRICK BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5139
Practice Address - Country:US
Practice Address - Phone:318-245-4113
Practice Address - Fax:318-588-8909
Is Sole Proprietor?:No
Enumeration Date:2022-11-18
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAR-1985106S00000X
LAC-130106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
0-22-14074OtherBACB
RBT-17-40016OtherBACB