Provider Demographics
NPI:1629776273
Name:KOERHUIS, CELESTE
Entity Type:Individual
Prefix:
First Name:CELESTE
Middle Name:
Last Name:KOERHUIS
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:VEREDA ST 1 URB MONTE VERDE REAL
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6501 ARLINGTON EXPRESSWAY B105 #2009
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211
Practice Address - Country:US
Practice Address - Phone:904-866-1857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH21627101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health