Provider Demographics
NPI:1326611120
Name:BALSA ALFONSO, ADAIRIS (LMHC)
Entity Type:Individual
Prefix:
First Name:ADAIRIS
Middle Name:
Last Name:BALSA ALFONSO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 W SAINT CONRAD ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-3042
Mailing Address - Country:US
Mailing Address - Phone:813-703-5759
Mailing Address - Fax:
Practice Address - Street 1:8252 DONALDSON DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-1224
Practice Address - Country:US
Practice Address - Phone:813-703-5759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
FLMH19268101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110637800Medicaid