Provider Demographics
NPI:1699531665
Name:CEBALLO, NICHOLAS CHRISTOPHER
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:CHRISTOPHER
Last Name:CEBALLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3406 70TH CT E
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-7381
Mailing Address - Country:US
Mailing Address - Phone:631-332-8623
Mailing Address - Fax:
Practice Address - Street 1:3030 UNIVERSITY PKWY STE 9015
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-2502
Practice Address - Country:US
Practice Address - Phone:941-404-5480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH25340101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health