Provider Demographics
NPI:1154952240
Name:BALLESTEROS, BAMBI
Entity type:Individual
Prefix:
First Name:BAMBI
Middle Name:
Last Name:BALLESTEROS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17562 GLADESWORTH LN
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91387-3807
Mailing Address - Country:US
Mailing Address - Phone:661-607-4869
Mailing Address - Fax:
Practice Address - Street 1:17562 GLADESWORTH LN
Practice Address - Street 2:
Practice Address - City:CANYON COUNTRY
Practice Address - State:CA
Practice Address - Zip Code:91387-3807
Practice Address - Country:US
Practice Address - Phone:661-607-4869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASPA2355S0801X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant