Healthcare Provider Details

I. General information

NPI: 1457382129
Provider Name (Legal Business Name): MICHELLE MARGARET BALESTRA MA, CCC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S HUNTINGTON AVE AUDIOLOGY 523/126
BOSTON MA
02130-4817
US

IV. Provider business mailing address

22 MATHAURS ST
MILTON MA
02186-4638
US

V. Phone/Fax

Practice location:
  • Phone: 617-232-9500
  • Fax:
Mailing address:
  • Phone: 617-232-9500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number568
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: