Provider Demographics
NPI:1558759753
Name:BALLESTAS, ALICIA (LCAT, ATR-BC)
Entity Type:Individual
Prefix:MISS
First Name:ALICIA
Middle Name:
Last Name:BALLESTAS
Suffix:
Gender:F
Credentials:LCAT, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15348 78TH RD
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-3542
Mailing Address - Country:US
Mailing Address - Phone:954-825-6319
Mailing Address - Fax:
Practice Address - Street 1:315 WYCKOFF AVE
Practice Address - Street 2:6TH FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-5384
Practice Address - Country:US
Practice Address - Phone:718-497-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001796-1221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist