Provider Demographics
NPI:1538947742
Name:FRESCO BALLADARES, ANIA ALICIA
Entity type:Individual
Prefix:
First Name:ANIA
Middle Name:ALICIA
Last Name:FRESCO BALLADARES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2791 S FLORIDA MANGO RD APT 406
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-2216
Mailing Address - Country:US
Mailing Address - Phone:561-719-2029
Mailing Address - Fax:
Practice Address - Street 1:3175 S CONGRESS AVE STE 203
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461-2562
Practice Address - Country:US
Practice Address - Phone:561-298-2399
Practice Address - Fax:561-200-2319
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-19
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-297645106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician