Provider Demographics
NPI:1508241373
Name:BALENO, KRISTEN (MED)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:
Last Name:BALENO
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3218 ERIE BLVD E
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:NY
Mailing Address - Zip Code:13214-1204
Mailing Address - Country:US
Mailing Address - Phone:315-430-5076
Mailing Address - Fax:
Practice Address - Street 1:3218 ERIE BLVD E
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:NY
Practice Address - Zip Code:13214-1204
Practice Address - Country:US
Practice Address - Phone:315-430-5076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1293605222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist