Healthcare Provider Details

I. General information

NPI: 1063272730
Provider Name (Legal Business Name): GABRIELA CEBALLOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 CRYSTAL RUN RD STE 201
MIDDLETOWN NY
10941-7010
US

IV. Provider business mailing address

815 ROMAN WAY
NEWBURGH NY
12550-8657
US

V. Phone/Fax

Practice location:
  • Phone: 845-692-4391
  • Fax:
Mailing address:
  • Phone: 845-913-6885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number010470
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: