Provider Demographics
NPI:1780715417
Name:YANISCH, CELESTE ROSE (PSYD)
Entity type:Individual
Prefix:DR
First Name:CELESTE
Middle Name:ROSE
Last Name:YANISCH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1596 UPPER AFTON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-6839
Mailing Address - Country:US
Mailing Address - Phone:651-772-2577
Mailing Address - Fax:
Practice Address - Street 1:3570 LEXINGTON AVE N
Practice Address - Street 2:SUITE 100
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-8049
Practice Address - Country:US
Practice Address - Phone:651-481-0664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3761103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN79G96YAOtherBCBSMN
MN941419300OtherMEDICAL ASSISTANCE NUMBER
MNHP46412OtherHEALTHPARTNERS NUMBER
MN680002011Medicare ID - Type UnspecifiedMEDICARE