Provider Demographics
NPI:1578649042
Name:MYLAND, CELESTA CARTRITE (MS,CCC/A)
Entity Type:Individual
Prefix:
First Name:CELESTA
Middle Name:CARTRITE
Last Name:MYLAND
Suffix:
Gender:F
Credentials:MS,CCC/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 WATER ST
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-3072
Mailing Address - Country:US
Mailing Address - Phone:952-925-5626
Mailing Address - Fax:952-925-0223
Practice Address - Street 1:675 WATER ST
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-3072
Practice Address - Country:US
Practice Address - Phone:952-925-5626
Practice Address - Fax:952-925-0223
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8430231H00000X, 231HA2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1578649042Medicaid