Provider Demographics
NPI:1114166832
Name:BALLESTE, WANDA DENISE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:DENISE
Last Name:BALLESTE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 GIVAN AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-2706
Mailing Address - Country:US
Mailing Address - Phone:917-299-8984
Mailing Address - Fax:
Practice Address - Street 1:667 E 233RD ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-2867
Practice Address - Country:US
Practice Address - Phone:917-299-8984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0162151235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist