Provider Demographics
NPI:1588912042
Name:INTERRANTE, CELESTE KYLE (PTA)
Entity type:Individual
Prefix:
First Name:CELESTE
Middle Name:KYLE
Last Name:INTERRANTE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 SE INTERNATIONAL WAY
Mailing Address - Street 2:STE. 100
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222
Mailing Address - Country:US
Mailing Address - Phone:971-206-5200
Mailing Address - Fax:971-206-5203
Practice Address - Street 1:2051 POTTERY AVE.
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366
Practice Address - Country:US
Practice Address - Phone:360-876-4461
Practice Address - Fax:360-876-4482
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160222785225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant