Basic Information
| Provider Information | |||||||||
| NPI: | 1457411654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALICH | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | ELI | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1263 N 15TH ST | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820722343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077458915 | ||||||||
| FaxNumber: | 3077458761 | ||||||||
| Practice Location | |||||||||
| Address1: | 1770 25TH AVE STE 206 | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806344949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077458915 | ||||||||
| FaxNumber: | 3077458761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 04/02/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 1335 | WY | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 0015268 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.