Healthcare Provider Details

I. General information

NPI: 1093088262
Provider Name (Legal Business Name): XICOTENCATL ADRIAN CEBALLOS MSW/CDP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2012
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 W MEEKER ST SUITE 201
KENT WA
98032-4323
US

IV. Provider business mailing address

1601 W MEEKER ST SUITE 201
KENT WA
98032-4323
US

V. Phone/Fax

Practice location:
  • Phone: 206-764-8019
  • Fax: 253-480-2937
Mailing address:
  • Phone: 206-764-8019
  • Fax: 253-480-2937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP 00006028
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSA 60471715
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: