Provider Demographics
NPI:1437316759
Name:CEBULA, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CEBULA
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 1:8 NORTHAMPTON RD
Mailing Address - Street 2:CHILDREN'S MH CLINIC
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-3224
Mailing Address - Country:US
Mailing Address - Phone:518-843-7520
Mailing Address - Fax:518-843-7537
Practice Address - Street 1:8 NORTHAMPTON RD
Practice Address - Street 2:CHILDREN'S MH CLINIC
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-3224
Practice Address - Country:US
Practice Address - Phone:518-843-7520
Practice Address - Fax:518-843-7537
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY067054104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker