Provider Demographics
NPI:1669951539
Name:CEBREROS, EDIT GUADALUPE
Entity type:Individual
Prefix:
First Name:EDIT
Middle Name:GUADALUPE
Last Name:CEBREROS
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 1:81496 FUCHSIA AVE
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-5331
Mailing Address - Country:US
Mailing Address - Phone:442-275-6414
Mailing Address - Fax:
Practice Address - Street 1:9333 BASELINE RD STE 290
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1300
Practice Address - Country:US
Practice Address - Phone:909-755-5220
Practice Address - Fax:951-905-1617
Is Sole Proprietor?:No
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANAOtherMEDICAL