Provider Demographics
NPI:1437273943
Name:BALBUENA, MARIA X
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:BALBUENA
Suffix:X
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-3720
Mailing Address - Country:US
Mailing Address - Phone:505-966-1866
Mailing Address - Fax:505-966-1865
Practice Address - Street 1:520 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-3720
Practice Address - Country:US
Practice Address - Phone:505-966-1866
Practice Address - Fax:505-966-1865
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM28109368103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM28109368OtherLICENSE