Provider Demographics
NPI:1699417550
Name:BALLESTEROS, RAE ANN ELEANOR (LMSW,LSSW)
Entity type:Individual
Prefix:
First Name:RAE ANN
Middle Name:ELEANOR
Last Name:BALLESTEROS
Suffix:
Gender:F
Credentials:LMSW,LSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1442
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38027-1442
Mailing Address - Country:US
Mailing Address - Phone:915-274-5353
Mailing Address - Fax:
Practice Address - Street 1:4821 AMERICAN WAY STE 315
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-2454
Practice Address - Country:US
Practice Address - Phone:901-515-6367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM9977104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker