Provider Demographics
NPI:1851912273
Name:LORENTE CEBALLO, SANDRA B (RBT-19-107988)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:B
Last Name:LORENTE CEBALLO
Suffix:
Gender:F
Credentials:RBT-19-107988
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5616 CREST HILL DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-4122
Mailing Address - Country:US
Mailing Address - Phone:813-471-8386
Mailing Address - Fax:
Practice Address - Street 1:3309 W WATERS AVE STE A
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2766
Practice Address - Country:US
Practice Address - Phone:813-898-0014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19-107988106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician