Provider Demographics
NPI:1700499209
Name:MB CLINICAL PSYCHOLOGY & CONSULTING, LLC
Entity Type:Organization
Organization Name:MB CLINICAL PSYCHOLOGY & CONSULTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLESTAS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:312-476-9588
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty