Provider Demographics
NPI:1619686755
Name:TISDELL, CELIA
Entity Type:Individual
Prefix:MISS
First Name:CELIA
Middle Name:
Last Name:TISDELL
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 1:6037 FRY RD STE 126
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-1804
Mailing Address - Country:US
Mailing Address - Phone:346-978-6097
Mailing Address - Fax:
Practice Address - Street 1:5006 EVENING MOON LN
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-5400
Practice Address - Country:US
Practice Address - Phone:346-978-6097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX247200000X, 376K00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No376K00000XNursing Service Related ProvidersNurse's Aide