Provider Demographics
NPI:1720369770
Name:BALOUKA, ROSA (OTA)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:
Last Name:BALOUKA
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:10930-0025
Mailing Address - Country:US
Mailing Address - Phone:845-827-5360
Mailing Address - Fax:845-827-5361
Practice Address - Street 1:615 STATE ROUTE 32
Practice Address - Street 2:
Practice Address - City:HIGHLAND MILLS
Practice Address - State:NY
Practice Address - Zip Code:10930-5200
Practice Address - Country:US
Practice Address - Phone:845-827-5360
Practice Address - Fax:845-827-5361
Is Sole Proprietor?:No
Enumeration Date:2011-09-05
Last Update Date:2011-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007928224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant