Provider Demographics
NPI:1902878366
Name:BALESTIN, GARY G (PHD, ABPN, LMFT)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:G
Last Name:BALESTIN
Suffix:
Gender:M
Credentials:PHD, ABPN, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 HUNTINGTON AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-5990
Mailing Address - Country:US
Mailing Address - Phone:650-588-3808
Mailing Address - Fax:650-873-5857
Practice Address - Street 1:1475 HUNTINGTON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-5990
Practice Address - Country:US
Practice Address - Phone:650-588-3808
Practice Address - Fax:650-873-5857
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5030103G00000X, 103TC0700X, 103TC2200X, 103TR0400X, 103TF0200X, 103TM1800X
CALMFT6806106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities