Provider Demographics
NPI:1861118077
Name:BALLESTERO, SHANIYA NICOLE
Entity type:Individual
Prefix:
First Name:SHANIYA
Middle Name:NICOLE
Last Name:BALLESTERO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANIYA
Other - Middle Name:NICOLE
Other - Last Name:BALLESTERO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:19853 OUTER DR STE 110
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2044
Mailing Address - Country:US
Mailing Address - Phone:313-622-4035
Mailing Address - Fax:
Practice Address - Street 1:19853 OUTER DR STE 110
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2044
Practice Address - Country:US
Practice Address - Phone:313-406-5056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103TC2200X
156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent