Provider Demographics
NPI:1932247590
Name:HISOLE CEBALLOS, LEILA MONTEFRIO (BSPT)
Entity Type:Individual
Prefix:MRS
First Name:LEILA
Middle Name:MONTEFRIO
Last Name:HISOLE CEBALLOS
Suffix:
Gender:F
Credentials:BSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MONMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-2514
Mailing Address - Country:US
Mailing Address - Phone:631-839-4059
Mailing Address - Fax:631-274-5940
Practice Address - Street 1:55 POST AVE
Practice Address - Street 2:STE. 205
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-4361
Practice Address - Country:US
Practice Address - Phone:516-338-0412
Practice Address - Fax:516-338-1106
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019468225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist