Provider Demographics
NPI:1073813325
Name:GNECO-VASQUEZ, CELESTE (LCSWR)
Entity Type:Individual
Prefix:MS
First Name:CELESTE
Middle Name:
Last Name:GNECO-VASQUEZ
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 OSBORNE AVENUE
Mailing Address - Street 2:RIVERHEAD SCHOOL DISTRICK
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901
Mailing Address - Country:US
Mailing Address - Phone:631-369-6701
Mailing Address - Fax:
Practice Address - Street 1:700 OSBORNE AVENUE
Practice Address - Street 2:RIVERHEAD CENTRAL SCHOOL DISTRICT
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901
Practice Address - Country:US
Practice Address - Phone:631-369-6701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY317311041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN2312-1OtherEMPIRE BLUE CROSS BLUE SHIELD
NYN2312-1Medicare PIN