Provider Demographics
NPI:1255800496
Name:CEBALLOS, LUIS ERNESTO
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:ERNESTO
Last Name:CEBALLOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15043 SW 109TH LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-2531
Mailing Address - Country:US
Mailing Address - Phone:786-495-2565
Mailing Address - Fax:786-364-1676
Practice Address - Street 1:9260 HAMMOCKS BLVD STE 202
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-1584
Practice Address - Country:US
Practice Address - Phone:786-353-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-69497106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician