Provider Demographics
NPI:1972103836
Name:ROSS, CELESTE ILENE
Entity Type:Individual
Prefix:
First Name:CELESTE
Middle Name:ILENE
Last Name:ROSS
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 1:1007 SMITH MANOR BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4227
Mailing Address - Country:US
Mailing Address - Phone:917-806-1978
Mailing Address - Fax:
Practice Address - Street 1:172 W 130TH ST OFC 1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-2030
Practice Address - Country:US
Practice Address - Phone:917-806-1978
Practice Address - Fax:201-595-0313
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No252Y00000XAgenciesEarly Intervention Provider Agency