Provider Demographics
NPI:1942427521
Name:BALLESTAS, MIRNA E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MIRNA
Middle Name:E
Last Name:BALLESTAS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5548 N VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3918
Mailing Address - Country:US
Mailing Address - Phone:773-610-8039
Mailing Address - Fax:
Practice Address - Street 1:4633 N WESTERN AVE STE 205
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2087
Practice Address - Country:US
Practice Address - Phone:312-476-9588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-005584101YM0800X
IL071.007650103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health