Provider Demographics
NPI:1033815337
Name:BALLESTEROS, MARTHA L (LCSW)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:L
Last Name:BALLESTEROS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11725 SNOW HAWK DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-0330
Mailing Address - Country:US
Mailing Address - Phone:915-630-6383
Mailing Address - Fax:
Practice Address - Street 1:11725 SNOW HAWK DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-0330
Practice Address - Country:US
Practice Address - Phone:915-630-6383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
TX648221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty