Provider Demographics
NPI:1386030138
Name:BALLESTEROS, KENDRA (PTA)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:BALLESTEROS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11960 WESTLINE INDUSTRIAL DR STE 201
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11960 WESTLINE INDUSTRIAL DRIVE #201
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3209
Practice Address - Country:US
Practice Address - Phone:314-890-0480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003029643172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker