Healthcare Provider Details

I. General information

NPI: 1467317537
Provider Name (Legal Business Name): ALISA BALDERAS MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12007 SUNRISE VALLEY DR
RESTON VA
20191-3479
US

IV. Provider business mailing address

2245 SOUTHGATE SQ
RESTON VA
20191-1232
US

V. Phone/Fax

Practice location:
  • Phone: 703-522-2089
  • Fax:
Mailing address:
  • Phone: 612-357-6405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: