Healthcare Provider Details

I. General information

NPI: 1710506977
Provider Name (Legal Business Name): THERESA SCIURBA BALLARDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E DEL MAR BLVD STE 119
PASADENA CA
91105-2551
US

IV. Provider business mailing address

200 E DEL MAR BLVD STE 119
PASADENA CA
91105-2551
US

V. Phone/Fax

Practice location:
  • Phone: 844-372-2019
  • Fax:
Mailing address:
  • Phone: 844-372-2019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number31448
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: