MEDICARE: NATHALYE CAROLINA BALISTRIRE LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	101YP2500X	Professional Counselor	LPC.0014010	CO

General Provider Information

NPI Number	:	1023449501
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHALYE CAROLINA BALISTRIRE LPC

Provider Business Mailing Address
First Line	:	2204 N EMERSON ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80205-5127
Country	:	US
Telephone Number	:	970-424-4061
Fax Number	:

Provider Business Practice Location Address
First Line	:	2204 N EMERSON ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80205-5127
Country	:	US
Telephone Number	:	970-424-4061
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2013
Last Update Date	:	06/19/2022

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