Provider Demographics
NPI:1104369693
Name:CELVI, HEATHER SUE
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:SUE
Last Name:CELVI
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 1:1037 PATHFINDER WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3242
Mailing Address - Country:US
Mailing Address - Phone:321-639-1224
Mailing Address - Fax:
Practice Address - Street 1:1037 PATHFINDER WAY
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3242
Practice Address - Country:US
Practice Address - Phone:321-639-1224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-01
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLC410337838460251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL171M00000XMedicaid