Provider Demographics
NPI:1780084681
Name:BALLARES, MARICEL
Entity type:Individual
Prefix:
First Name:MARICEL
Middle Name:
Last Name:BALLARES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PROVIDER
Mailing Address - Street 1:94-877 LUMIIKI ST
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-3933
Mailing Address - Country:US
Mailing Address - Phone:808-729-3216
Mailing Address - Fax:808-200-5552
Practice Address - Street 1:94-877 LUMIIKI ST
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-3933
Practice Address - Country:US
Practice Address - Phone:808-729-3216
Practice Address - Fax:808-200-5552
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIHCBS 09-2434253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency