Provider Demographics
NPI:1972675874
Name:CEBALLOS, CARMEN R (LCSW-R)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:R
Last Name:CEBALLOS
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BROADHOLLOW RD STE 108
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-4813
Mailing Address - Country:US
Mailing Address - Phone:631-769-7763
Mailing Address - Fax:631-769-7763
Practice Address - Street 1:100 BROADHOLLOW RD STE 108
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-4813
Practice Address - Country:US
Practice Address - Phone:631-769-7763
Practice Address - Fax:631-769-7763
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2019-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0767911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
12769900OtherCAQH