Provider Demographics
NPI:1134896863
Name:BALLESTEROS, ISSAC ROY (101Y00000X)
Entity type:Individual
Prefix:
First Name:ISSAC
Middle Name:ROY
Last Name:BALLESTEROS
Suffix:
Gender:M
Credentials:101Y00000X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 S HULEN ST STE 436
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4910
Mailing Address - Country:US
Mailing Address - Phone:817-952-8180
Mailing Address - Fax:
Practice Address - Street 1:4200 S HULEN ST STE 436
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4910
Practice Address - Country:US
Practice Address - Phone:817-952-8180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2025-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99657101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor