MEDICARE: MS. MARTHA R. BALDERAS BA

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1609199330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARTHA R. BALDERAS BA

Provider Business Mailing Address
First Line	:	6618 NW 10TH ST
Second Line	:	APT. B
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73127-5442
Country	:	US
Telephone Number	:	405-488-5454
Fax Number	:

Provider Business Practice Location Address
First Line	:	6618 NW 10TH ST
Second Line	:	APT. B
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73127-5442
Country	:	US
Telephone Number	:	405-488-5454
Fax Number	:

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

Provider Enumeration Date	:	03/09/2010
Last Update Date	:	03/09/2010

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