Provider Demographics
NPI:1104382035
Name:PENROSE, CELESTE MARIE
Entity Type:Individual
Prefix:
First Name:CELESTE
Middle Name:MARIE
Last Name:PENROSE
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 1:5151 N PALM AVE STE 750
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-2221
Mailing Address - Country:US
Mailing Address - Phone:559-325-4302
Mailing Address - Fax:559-226-0199
Practice Address - Street 1:5151 N PALM AVE STE 750
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93704-2221
Practice Address - Country:US
Practice Address - Phone:559-325-4302
Practice Address - Fax:559-226-0199
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111333101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health