Provider Demographics
NPI:1669093464
Name:WALLACE, CELESTE OROZCO
Entity type:Individual
Prefix:
First Name:CELESTE
Middle Name:OROZCO
Last Name:WALLACE
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 1:3315 GIBSON PL
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-1728
Mailing Address - Country:US
Mailing Address - Phone:915-603-7789
Mailing Address - Fax:
Practice Address - Street 1:21615 HAWTHORNE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-6670
Practice Address - Country:US
Practice Address - Phone:310-371-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-03
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30117235Z00000X
CA13631235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist