Provider Demographics
NPI:1790412609
Name:CELISIE, WALLYS
Entity Type:Individual
Prefix:
First Name:WALLYS
Middle Name:
Last Name:CELISIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3324 E RAY RD UNIT 1706
Mailing Address - Street 2:
Mailing Address - City:HIGLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85236-4581
Mailing Address - Country:US
Mailing Address - Phone:561-325-1657
Mailing Address - Fax:
Practice Address - Street 1:901 W 24TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6384
Practice Address - Country:US
Practice Address - Phone:928-726-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8647225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist