Healthcare Provider Details

I. General information

NPI: 1821963307
Provider Name (Legal Business Name): EDWIN ADAN BALLESTEROS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2025
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

762 GRISWOLD AVE
SAN FERNANDO CA
91340-2105
US

IV. Provider business mailing address

762 GRISWOLD AVE
SAN FERNANDO CA
91340-2105
US

V. Phone/Fax

Practice location:
  • Phone: 747-500-9405
  • Fax: 747-500-9405
Mailing address:
  • Phone: 747-500-9405
  • Fax: 747-500-9405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number22610
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: