Organization
MB CLINICAL PSYCHOLOGY & CONSULTING, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MIRNA BALLESTAS PSY.D. (CLINICAL PSYCHOLOGIST)
(312) 476-9588
Entity
Organization
Contact information
Practice address
4633 N WESTERN AVE STE 205, CHICAGO, IL 60625-2087
(312) 476-9588
Mailing address
5548 N VIRGINIA AVE, CHICAGO, IL 60625-3918
(773) 610-8039
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
—
—
103TC0700X
Clinical Psychologist
Primary
—
—
103TC2200X
Clinical Child & Adolescent Psychologist
—
—
103TF0000X
Family Psychologist
—
—
103TH0004X
Health Psychologist
—
—
103TP2701X
Group Psychotherapy Psychologist
—
—
Other
Enumeration date
08/25/2020
Last updated
08/25/2020
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