Provider Demographics
NPI:1144879032
Name:BALSAM, SHERI JILL (PSYD)
Entity type:Individual
Prefix:DR
First Name:SHERI
Middle Name:JILL
Last Name:BALSAM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041 RIDGE AVE APT 18508
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1557
Mailing Address - Country:US
Mailing Address - Phone:516-732-1735
Mailing Address - Fax:
Practice Address - Street 1:1930 S BROAD ST UNIT 11
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-2328
Practice Address - Country:US
Practice Address - Phone:800-897-5252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS018873103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty