Healthcare Provider Details

I. General information

NPI: 1013493535
Provider Name (Legal Business Name): NICOLE BALISTRIERI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5025 E WASHINGTON ST
PHOENIX AZ
85034-7437
US

IV. Provider business mailing address

4530 E MUIRWOOD DR STE 103
PHOENIX AZ
85048-7693
US

V. Phone/Fax

Practice location:
  • Phone: 602-773-5773
  • Fax:
Mailing address:
  • Phone: 480-610-6981
  • Fax: 480-898-7419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBEH-001011
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: