Provider Demographics
NPI:1407723190
Name:VANDERBURG, CELISA MALIKA
Entity type:Individual
Prefix:MS
First Name:CELISA
Middle Name:MALIKA
Last Name:VANDERBURG
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 1:907 TOWNEHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-2824
Mailing Address - Country:US
Mailing Address - Phone:646-655-8204
Mailing Address - Fax:
Practice Address - Street 1:64 OLD RIVERHEAD RD
Practice Address - Street 2:
Practice Address - City:WESTHAMPTON BEACH
Practice Address - State:NY
Practice Address - Zip Code:11978-1451
Practice Address - Country:US
Practice Address - Phone:646-655-8204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-20
Last Update Date:2025-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY127117104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker