Provider Demographics
NPI:1669099479
Name:CEBALLOS, AMY GISELLE
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:GISELLE
Last Name:CEBALLOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 W HOSPITALITY LN STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3210
Mailing Address - Country:US
Mailing Address - Phone:909-266-2700
Mailing Address - Fax:
Practice Address - Street 1:325 W HOSPITALITY LN STE 104
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3210
Practice Address - Country:US
Practice Address - Phone:909-266-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-26
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator