Provider Demographics
NPI:1457818296
Name:CEBALLO-HERNANDEZ, HELEN RICHELLE
Entity type:Individual
Prefix:
First Name:HELEN
Middle Name:RICHELLE
Last Name:CEBALLO-HERNANDEZ
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 1:2678 RICHMOND ST NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-2331
Mailing Address - Country:US
Mailing Address - Phone:917-837-9913
Mailing Address - Fax:
Practice Address - Street 1:534 FOUNTAIN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3422
Practice Address - Country:US
Practice Address - Phone:616-591-9663
Practice Address - Fax:616-456-1324
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016869101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional