Provider Demographics
NPI:1598479941
Name:CELLICH, CAROLINE R
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:R
Last Name:CELLICH
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 1:2240 ARCTIC CIR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-3004
Mailing Address - Country:US
Mailing Address - Phone:561-523-0791
Mailing Address - Fax:
Practice Address - Street 1:640 BREVARD AVE STE 104
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7849
Practice Address - Country:US
Practice Address - Phone:321-433-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW17927104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker