Provider Demographics
NPI:1154982171
Name:CELESTINE, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CELESTINE
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 1:113 W CONVENT ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-6903
Mailing Address - Country:US
Mailing Address - Phone:337-534-0770
Mailing Address - Fax:337-534-4370
Practice Address - Street 1:113 W CONVENT ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501
Practice Address - Country:US
Practice Address - Phone:337-534-0770
Practice Address - Fax:337-534-4370
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-21
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator