Provider Demographics
NPI:1801169057
Name:BALSAM, AVITAL (SLP-MA)
Entity type:Individual
Prefix:
First Name:AVITAL
Middle Name:
Last Name:BALSAM
Suffix:
Gender:F
Credentials:SLP-MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08904-3711
Mailing Address - Country:US
Mailing Address - Phone:516-361-0985
Mailing Address - Fax:888-548-7035
Practice Address - Street 1:1708 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:08904-3711
Practice Address - Country:US
Practice Address - Phone:516-361-0985
Practice Address - Fax:888-548-7035
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-20
Last Update Date:2024-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS01197100235Z00000X
NY010377235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist