Provider Demographics
NPI:1407403777
Name:CELESTE MICHELE UTHE-BUROW
Entity Type:Organization
Organization Name:CELESTE MICHELE UTHE-BUROW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CELESTE
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:UTHE-BUROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-201-0104
Mailing Address - Street 1:1108 W GLEN EAGLE CIR
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-4122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1108 W GLEN EAGLE CIR
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-4122
Practice Address - Country:US
Practice Address - Phone:605-201-0104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDLMFT1077OtherSTATE LIC