Provider Demographics
NPI:1629315015
Name:BALLEW, ITZEL CEBALLOS
Entity Type:Individual
Prefix:MRS
First Name:ITZEL
Middle Name:CEBALLOS
Last Name:BALLEW
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 1:2351 CARDINAL LN
Mailing Address - Street 2:ANNEX B
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-3743
Mailing Address - Country:US
Mailing Address - Phone:619-573-2227
Mailing Address - Fax:
Practice Address - Street 1:2351 CARDINAL LN
Practice Address - Street 2:ANNEX B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-3743
Practice Address - Country:US
Practice Address - Phone:619-573-2227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-06
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 390200000X
CA79127106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program