Provider Demographics
NPI:1245995372
Name:LIVE WELL PSYCHOTHERAPY LCSW PLLC
Entity type:Organization
Organization Name:LIVE WELL PSYCHOTHERAPY LCSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CEBALLOS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:631-769-7763
Mailing Address - Street 1:26 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-6714
Mailing Address - Country:US
Mailing Address - Phone:646-932-6759
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-03
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty