Basic Information
Provider Information | |||||||||
NPI: | 1164776431 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BALSAMO | ||||||||
FirstName: | BONNIE | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LICSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 173 MIDDLE ST | ||||||||
Address2: |   | ||||||||
City: | LANCASTER | ||||||||
State: | NH | ||||||||
PostalCode: | 035843508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6037885029 | ||||||||
FaxNumber: | 6037885607 | ||||||||
Practice Location | |||||||||
Address1: | 141 CORLISS LN | ||||||||
Address2: |   | ||||||||
City: | COLEBROOK | ||||||||
State: | NH | ||||||||
PostalCode: | 035763206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6037885095 | ||||||||
FaxNumber: | 6037885607 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/07/2012 | ||||||||
LastUpdateDate: | 07/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/12/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | NCL.0012968 | CO | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 2009 | NH | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 2009 | NH | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 3135038 | 05 | NH |   | MEDICAID |