Provider Demographics
NPI:1790312783
Name:PENTAGULIO, CELENA DERDERIAN
Entity Type:Individual
Prefix:
First Name:CELENA
Middle Name:DERDERIAN
Last Name:PENTAGULIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CELENA
Other - Middle Name:JOYCE
Other - Last Name:DERDERIAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1200 N STATE STREET CLINIC TOWER
Mailing Address - Street 2:SUITE A7D
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1029
Mailing Address - Country:US
Mailing Address - Phone:323-409-5555
Mailing Address - Fax:
Practice Address - Street 1:1200 N STATE STREET CLINIC TOWER
Practice Address - Street 2:SUITE A7D
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1029
Practice Address - Country:US
Practice Address - Phone:323-409-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA1786332084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program