Provider Demographics
NPI:1629213442
Name:CEBALLOS, MONICA (OT)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:CEBALLOS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6611 BOEING DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-1010
Mailing Address - Country:US
Mailing Address - Phone:915-780-6576
Mailing Address - Fax:
Practice Address - Street 1:6611 BOEING DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-1010
Practice Address - Country:US
Practice Address - Phone:915-780-6576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-08
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110371225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198396701Medicaid