Provider Demographics
NPI:1205005915
Name:BALLESTER, SANDRA M (PSY D)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
Last Name:BALLESTER
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 135157
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34713-5157
Mailing Address - Country:US
Mailing Address - Phone:863-424-0194
Mailing Address - Fax:
Practice Address - Street 1:602 COVENTRY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33897-3899
Practice Address - Country:US
Practice Address - Phone:863-424-0194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-27
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7428103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical