Provider Demographics
NPI:1336792373
Name:DE JESUS, CELINE (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:CELINE
Middle Name:
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2228 E CAMPBELL AVE APT 228
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5550
Mailing Address - Country:US
Mailing Address - Phone:480-689-0272
Mailing Address - Fax:
Practice Address - Street 1:13385 W MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2631
Practice Address - Country:US
Practice Address - Phone:623-986-5110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-007874225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty