Provider Demographics
NPI:1710506977
Name:BALLARDO, THERESA SCIURBA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:SCIURBA
Last Name:BALLARDO
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 1:200 E DEL MAR BLVD STE 119
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2551
Mailing Address - Country:US
Mailing Address - Phone:844-372-2019
Mailing Address - Fax:
Practice Address - Street 1:200 E DEL MAR BLVD STE 119
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2551
Practice Address - Country:US
Practice Address - Phone:844-372-2019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-08
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31448103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical