Provider Demographics
NPI:1679193361
Name:BALDERAS, SELENA
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:BALDERAS
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 1:435 N 35TH AVE LOT 270
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-9496
Mailing Address - Country:US
Mailing Address - Phone:970-301-5737
Mailing Address - Fax:
Practice Address - Street 1:710 11TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-6405
Practice Address - Country:US
Practice Address - Phone:970-301-5737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
COW629256Medicaid