Provider Demographics
NPI:1508554593
Name:CEPERO, MALENA
Entity Type:Individual
Prefix:
First Name:MALENA
Middle Name:
Last Name:CEPERO
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 1:4958 CLINTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-2269
Mailing Address - Country:US
Mailing Address - Phone:786-865-2160
Mailing Address - Fax:
Practice Address - Street 1:4958 CLINTON BLVD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-2269
Practice Address - Country:US
Practice Address - Phone:786-865-2160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-264702106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty