Basic Information
| Provider Information | |||||||||
| NPI: | 1093710634 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALASU | ||||||||
| FirstName: | ANCA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 249 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986327154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604142048 | ||||||||
| FaxNumber: | 3605756749 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986323256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604142222 | ||||||||
| FaxNumber: | 3604142220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | MD00045183 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 8906765 | 01 | WA | CRIME VICTIMS | OTHER | 0199580 | 01 | WA | LABOR & IND | OTHER | 023269 | 05 | OR | MEDICAID | 8433740 | 05 | WA | MEDICAID |