Provider Demographics
NPI:1215508452
Name:CELESTE, KELLY (EDD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CELESTE
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 RUMFORD AVE APT 411
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048-2150
Mailing Address - Country:US
Mailing Address - Phone:774-254-1412
Mailing Address - Fax:
Practice Address - Street 1:150 RUMFORD AVE APT 411
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:MA
Practice Address - Zip Code:02048-2150
Practice Address - Country:US
Practice Address - Phone:774-254-1412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA494300103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health