Provider Demographics
NPI:1114585353
Name:CEBALLOS, CAROLAY
Entity Type:Individual
Prefix:
First Name:CAROLAY
Middle Name:
Last Name:CEBALLOS
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 1:651 W 190TH ST APT 45
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-4132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:579 COURTLANDT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5013
Practice Address - Country:US
Practice Address - Phone:718-485-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No172V00000XOther Service ProvidersCommunity Health Worker