Provider Demographics
NPI:1700588399
Name:BALLESTEROS, ADRIANE CLARK SALAZAR (PTA)
Entity type:Individual
Prefix:
First Name:ADRIANE CLARK
Middle Name:SALAZAR
Last Name:BALLESTEROS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5741 VAN HORN ST FL 3
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-5090
Mailing Address - Country:US
Mailing Address - Phone:347-839-9275
Mailing Address - Fax:
Practice Address - Street 1:5741 VAN HORN ST FL 3
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5090
Practice Address - Country:US
Practice Address - Phone:347-839-9275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012564225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant