=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649852617
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ESPERANZA BALLENILLA LCSW-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2021
-----------------------------------------------------
Last Update Date | 10/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325 HOSPITAL DR STE 106
-----------------------------------------------------
City | GLEN BURNIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21061-5806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-430-2998
-----------------------------------------------------
Fax | 443-431-8978
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7310 RITCHIE HWY SUITE #200-GB37
-----------------------------------------------------
City | GLEN BURNIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-886-7324
-----------------------------------------------------
Fax | 410-744-0091
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------