Provider Demographics
NPI:1679020655
Name:BALSANO, REBEKAH LEE
Entity type:Individual
Prefix:MRS
First Name:REBEKAH
Middle Name:LEE
Last Name:BALSANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 BEDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14216-3135
Mailing Address - Country:US
Mailing Address - Phone:716-297-0798
Mailing Address - Fax:716-297-0998
Practice Address - Street 1:332 BEDFORD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14216-3135
Practice Address - Country:US
Practice Address - Phone:716-297-0798
Practice Address - Fax:716-297-0998
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1410441174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1410441OtherNEW YORK STATE