Provider Demographics
NPI:1346740560
Name:CEPEDA, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:CEPEDA
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 1:140 ROUTE 303
Mailing Address - Street 2:
Mailing Address - City:VALLEY COTTAGE
Mailing Address - State:NY
Mailing Address - Zip Code:10989
Mailing Address - Country:US
Mailing Address - Phone:845-267-2172
Mailing Address - Fax:
Practice Address - Street 1:140 ROUTE 303
Practice Address - Street 2:
Practice Address - City:VALLEY COTTAGE
Practice Address - State:NY
Practice Address - Zip Code:10989
Practice Address - Country:US
Practice Address - Phone:845-267-2172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY376387427171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY376387427Medicaid