Provider Demographics
NPI:1225743206
Name:HILDACK, CELINE RENAY
Entity Type:Individual
Prefix:
First Name:CELINE
Middle Name:RENAY
Last Name:HILDACK
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 1:5500 MARKET ST STE 118
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-2616
Mailing Address - Country:US
Mailing Address - Phone:330-991-9117
Mailing Address - Fax:
Practice Address - Street 1:5500 MARKET ST STE 118
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-2616
Practice Address - Country:US
Practice Address - Phone:330-991-9117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-13
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-23-67853103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty