Provider Demographics
NPI:1083853907
Name:CEBALLOS, LAURA SUZANNE (PHD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:SUZANNE
Last Name:CEBALLOS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:SUZANNE
Other - Last Name:HAMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1300 NATIONAL DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-1947
Mailing Address - Country:US
Mailing Address - Phone:916-928-2594
Mailing Address - Fax:
Practice Address - Street 1:1300 NATIONAL DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-1947
Practice Address - Country:US
Practice Address - Phone:916-928-2594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19340103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic