Provider Demographics
NPI:1407695596
Name:PENAFIEL BALLADARES, MELISA ANDREA
Entity type:Individual
Prefix:MRS
First Name:MELISA
Middle Name:ANDREA
Last Name:PENAFIEL BALLADARES
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 1:451 TAYLOR GROVES DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33898-5138
Mailing Address - Country:US
Mailing Address - Phone:863-320-4686
Mailing Address - Fax:
Practice Address - Street 1:451 TAYLOR GROVES DR
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33898-5138
Practice Address - Country:US
Practice Address - Phone:863-320-4686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-20
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-342722106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician