Provider Demographics
NPI:1598318362
Name:BALLESTEROS, SONIA MIRELLA
Entity Type:Individual
Prefix:
First Name:SONIA
Middle Name:MIRELLA
Last Name:BALLESTEROS
Suffix:
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 1:2324 MERMAID AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-2208
Mailing Address - Country:US
Mailing Address - Phone:917-442-2482
Mailing Address - Fax:
Practice Address - Street 1:10818 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4748
Practice Address - Country:US
Practice Address - Phone:646-599-3486
Practice Address - Fax:888-975-7704
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178373021174400000X
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist