Provider Demographics
NPI:1093088262
Name:CEBALLOS, XICOTENCATL ADRIAN (MSW/CDP)
Entity Type:Individual
Prefix:
First Name:XICOTENCATL
Middle Name:ADRIAN
Last Name:CEBALLOS
Suffix:
Gender:M
Credentials:MSW/CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 W MEEKER ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-4323
Mailing Address - Country:US
Mailing Address - Phone:206-764-8019
Mailing Address - Fax:253-480-2937
Practice Address - Street 1:1601 W MEEKER ST
Practice Address - Street 2:SUITE 201
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-4323
Practice Address - Country:US
Practice Address - Phone:206-764-8019
Practice Address - Fax:253-480-2937
Is Sole Proprietor?:No
Enumeration Date:2012-02-17
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP 00006028101YA0400X
WASA 60471715101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)