Provider Demographics
NPI:1770723702
Name:BALCEZAK, JUDITH DISSELL (LPC)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:DISSELL
Last Name:BALCEZAK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 GROVE ST.
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790
Mailing Address - Country:US
Mailing Address - Phone:860-482-5558
Mailing Address - Fax:
Practice Address - Street 1:132 GROVE ST.
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790
Practice Address - Country:US
Practice Address - Phone:860-482-5558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-04
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CT2885101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor