Provider Demographics
NPI:1518277821
Name:BALDERAS, ALBERT FELICIANO
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:FELICIANO
Last Name:BALDERAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N INDIAN HILL BLVD # 627
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-4611
Mailing Address - Country:US
Mailing Address - Phone:909-559-6546
Mailing Address - Fax:
Practice Address - Street 1:855 N EUCLID AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-2729
Practice Address - Country:US
Practice Address - Phone:909-983-2020
Practice Address - Fax:909-983-6847
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT127798106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA951946482Medicaid