Provider Demographics
NPI:1184601270
Name:DERECHO, CELESTE (PHD)
Entity type:Individual
Prefix:
First Name:CELESTE
Middle Name:
Last Name:DERECHO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 HARNESS LN
Mailing Address - Street 2:
Mailing Address - City:SUDBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01776-1502
Mailing Address - Country:US
Mailing Address - Phone:978-579-0013
Mailing Address - Fax:
Practice Address - Street 1:398 NEPONSET AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-3134
Practice Address - Country:US
Practice Address - Phone:617-282-3200
Practice Address - Fax:617-282-7928
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7879103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA59862Medicare ID - Type Unspecified