Provider Demographics
NPI:1750671855
Name:BALLESTAS, JORGE ALBERTO (MS CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:ALBERTO
Last Name:BALLESTAS
Suffix:
Gender:M
Credentials:MS CCC-SLP
Other - Prefix:MR
Other - First Name:JORGE
Other - Middle Name:ALBERTO
Other - Last Name:BALLESTAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:3175 E TREMONT AVE
Mailing Address - Street 2:SUITE 2/F
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-5700
Mailing Address - Country:US
Mailing Address - Phone:718-239-8239
Mailing Address - Fax:718-770-7686
Practice Address - Street 1:4122 42ND ST APT 5C
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-2711
Practice Address - Country:US
Practice Address - Phone:646-373-4499
Practice Address - Fax:718-406-9937
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015216-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist