MEDICARE: MARIA REBECCA BALLESTEROS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LPCC1978	CA

General Provider Information

NPI Number	:	1285330027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA REBECCA BALLESTEROS

Provider Business Mailing Address
First Line	:	PO BOX 16836
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92176-6836
Country	:	US
Telephone Number	:	619-942-1027
Fax Number	:

Provider Business Practice Location Address
First Line	:	3218 1/2 ADAMS AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92116-1644
Country	:	US
Telephone Number	:	619-942-1027
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2023
Last Update Date	:	02/03/2023

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