Individual
DR. MIRNA E BALLESTAS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PSY.D.
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
101YM0800X
Mental Health Counselor
180-005584
IL
103TC0700X
Clinical Psychologist
Primary
071.007650
IL
Other
Enumeration date
04/18/2007
Last updated
08/25/2020
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