Provider Demographics
NPI:1578977781
Name:BALSECA, AMANDA ELYSE (LAC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELYSE
Last Name:BALSECA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE, BOX 665
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642
Mailing Address - Country:US
Mailing Address - Phone:585-275-5321
Mailing Address - Fax:585-340-9745
Practice Address - Street 1:601 ELMWOOD AVE,
Practice Address - Street 2:BOX 665
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642
Practice Address - Country:US
Practice Address - Phone:585-275-5321
Practice Address - Fax:585-340-0745
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-16
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5312171100000X
NY005312-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist