Provider Demographics
NPI:1609114859
Name:CEBALLOS, DIANE MARIE
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:MARIE
Last Name:CEBALLOS
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 1:2119 24TH RD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-3447
Mailing Address - Country:US
Mailing Address - Phone:347-623-5905
Mailing Address - Fax:
Practice Address - Street 1:611 BROADWAY
Practice Address - Street 2:SUITE 908
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-2608
Practice Address - Country:US
Practice Address - Phone:212-473-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP86861225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics