Provider Demographics
NPI:1730271792
Name:BALOG, CYNTHIA DEWATERS (LCPC LCADC)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:DEWATERS
Last Name:BALOG
Suffix:
Gender:F
Credentials:LCPC LCADC
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:JUNE
Other - Last Name:DEWATERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3314 PAPER MILL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:MD
Mailing Address - Zip Code:21131-1446
Mailing Address - Country:US
Mailing Address - Phone:410-802-4049
Mailing Address - Fax:866-561-6670
Practice Address - Street 1:3314 PAPER MILL RD STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:MD
Practice Address - Zip Code:21131-1446
Practice Address - Country:US
Practice Address - Phone:410-802-4049
Practice Address - Fax:866-561-6670
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA362101YA0400X
MDLC1289101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD461922374OtherCIGNA
MD676829OtherBEACON HEALTH OPTIONS
RS830034OtherCAREFIRST GHMSI
MD699558600Medicaid
62464101OtherCAREFIRST MD
MD699558600Medicaid