Healthcare Provider Details

I. General information

NPI: 1649150228
Provider Name (Legal Business Name): JEZA DANIELLE BALAZO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2025
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80-46 KEW GARDENS RD,
KEW GARDENS NY
11415
US

IV. Provider business mailing address

4419 74TH ST 3F
ELMHURST NY
11373
US

V. Phone/Fax

Practice location:
  • Phone: 718-261-1000
  • Fax:
Mailing address:
  • Phone: 845-891-0257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number052667
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: