Basic Information
| Provider Information | |||||||||
| NPI: | 1699063156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALESTRERI | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2562 W SCHAUMBURG RD | ||||||||
| Address2: | |||||||||
| City: | SCHAUMBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601943897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475193485 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2011 | ||||||||
| LastUpdateDate: | 04/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1208651 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 070020951 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 192079501 | 05 | TX | MEDICAID |