Provider Demographics
NPI:1568964401
Name:CELEC, AMY JOY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JOY
Last Name:CELEC
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 1:1220 SMITH COVE CIR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6828
Mailing Address - Country:US
Mailing Address - Phone:757-620-8972
Mailing Address - Fax:
Practice Address - Street 1:5649 BAYSIDE RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-3410
Practice Address - Country:US
Practice Address - Phone:757-648-2080
Practice Address - Fax:757-460-7513
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2203000134235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA$$$$$$$$$Medicaid