Basic Information
| Provider Information | |||||||||
| NPI: | 1730108119 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALACKI | ||||||||
| FirstName: | MARGARET | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | PROF. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSN-CRNP/PMH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FOOTE | ||||||||
| OtherFirstName: | MARGARET | ||||||||
| OtherMiddleName: | RUTH | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 803 LATCHMERE CT | ||||||||
| Address2: | UNIT 103 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214018268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108252281 | ||||||||
| FaxNumber: | 4108250757 | ||||||||
| Practice Location | |||||||||
| Address1: | 1407 YORK RD | ||||||||
| Address2: | SUITE 309 | ||||||||
| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210936097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108252281 | ||||||||
| FaxNumber: | 4108250757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 07/12/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | R061828 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 364S00000X | R061828 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
ID Information
| ID | Type | State | Issuer | Description | R061828 | 01 | MD | LICENSE | OTHER | MB0224890 | 01 | MD | DEA | OTHER | N51941 | 01 | MD | CDS | OTHER |