Provider Demographics
NPI:1467230425
Name:CEBALLOS, JOHANNA (LMSW)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:CEBALLOS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5530 NETHERLAND AVE APT 1C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-2364
Mailing Address - Country:US
Mailing Address - Phone:347-735-1026
Mailing Address - Fax:
Practice Address - Street 1:85 W BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4015
Practice Address - Country:US
Practice Address - Phone:718-716-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-20
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)