Provider Demographics
NPI:1215607965
Name:BALBUENA, ADOLFO ANGEL JR
Entity type:Individual
Prefix:
First Name:ADOLFO
Middle Name:ANGEL
Last Name:BALBUENA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 AVENUE OF AMERICAS, NEW YORK NY
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:NY
Mailing Address - Zip Code:10011-9904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:109 E 115TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-1186
Practice Address - Country:US
Practice Address - Phone:212-886-4027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker