Healthcare Provider Details

I. General information

NPI: 1609482496
Provider Name (Legal Business Name): ENRIQUE CEBALLOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18818 OUTER HWY 18
APPLE VALLEY CA
92307-2323
US

IV. Provider business mailing address

18818 OUTER HWY 18
APPLE VALLEY CA
92307-2323
US

V. Phone/Fax

Practice location:
  • Phone: 888-743-1478
  • Fax:
Mailing address:
  • Phone: 909-756-0431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number152769
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: