Provider Demographics
NPI:1508964966
Name:NETTLES, CELESTE H (MBS, MS, LPC)
Entity Type:Individual
Prefix:
First Name:CELESTE
Middle Name:H
Last Name:NETTLES
Suffix:
Gender:F
Credentials:MBS, MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5315 BENNINGTON DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-3418
Mailing Address - Country:US
Mailing Address - Phone:336-500-9983
Mailing Address - Fax:
Practice Address - Street 1:445 DOLLEY MADISON RD STE B
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-5166
Practice Address - Country:US
Practice Address - Phone:336-500-9983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5059101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103048Medicaid