Provider Demographics
NPI:1295207421
Name:CEPHAS, ANTHONY DECARLOS
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:DECARLOS
Last Name:CEPHAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3606 CRESCENT ST # 1
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11106-3922
Mailing Address - Country:US
Mailing Address - Phone:929-290-8521
Mailing Address - Fax:
Practice Address - Street 1:19 W 34TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3006
Practice Address - Country:US
Practice Address - Phone:929-290-8521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1056111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1752Medicaid