MEDICARE: DR. GARY G. BALESTIN PHD, ABPN, LMFT

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	103G00000X	Clinical Neuropsychologist	PSY5030	CA
2	103TC0700X	Clinical Psychologist	PSY5030	CA
3	106H00000X	Marriage & Family Therapist	LMFT6806	CA
4	103TC2200X	Clinical Child & Adolescent Psychologist	PSY5030	CA
5	103TR0400X	Rehabilitation Psychologist	PSY5030	CA
6	103TF0200X	Forensic Psychologist	PSY5030	CA
7	103TM1800X	Intellectual & Developmental Disabilities Psychologist	PSY5030	CA

General Provider Information

NPI Number	:	1902878366
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY G. BALESTIN PHD, ABPN, LMFT

Provider Business Mailing Address
First Line	:	1475 HUNTINGTON AVE
Second Line	:	SUITE 201
City	:	SOUTH SAN FRANCISCO
State	:	CA
Zip	:	94080-5990
Country	:	US
Telephone Number	:	650-588-3808
Fax Number	:	650-873-5857

Provider Business Practice Location Address
First Line	:	1475 HUNTINGTON AVE
Second Line	:	SUITE 201
City	:	SOUTH SAN FRANCISCO
State	:	CA
Zip	:	94080-5990
Country	:	US
Telephone Number	:	650-588-3808
Fax Number	:	650-873-5857

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

Provider Enumeration Date	:	02/01/2006
Last Update Date	:	09/11/2025

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