Provider Demographics
NPI:1558558247
Name:RANDALL, CELESTE (PT)
Entity Type:Individual
Prefix:MS
First Name:CELESTE
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5535 BALBOA BLVD
Mailing Address - Street 2:216
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1516
Mailing Address - Country:US
Mailing Address - Phone:818-784-3096
Mailing Address - Fax:818-786-3097
Practice Address - Street 1:5535 BALBOA BLVD
Practice Address - Street 2:216
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1516
Practice Address - Country:US
Practice Address - Phone:818-784-3096
Practice Address - Fax:818-786-3097
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT8407225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT8407AMedicare PIN