Provider Demographics
NPI:1609244185
Name:BALASSONE, MARCO MATTEO (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:MARCO
Middle Name:MATTEO
Last Name:BALASSONE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 CAM FELLA ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-2393
Mailing Address - Country:US
Mailing Address - Phone:860-794-8719
Mailing Address - Fax:
Practice Address - Street 1:464 MAIN ST
Practice Address - Street 2:
Practice Address - City:AGAWAM
Practice Address - State:MA
Practice Address - Zip Code:01001-1826
Practice Address - Country:US
Practice Address - Phone:860-794-8719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4725225100000X
MA24033225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1609244185Medicaid