Provider Demographics
NPI:1912730458
Name:REWILD, PLLC
Entity type:Organization
Organization Name:REWILD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CELESTE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:240-753-2583
Mailing Address - Street 1:5806 GROVE AVE # 122
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-2630
Mailing Address - Country:US
Mailing Address - Phone:240-753-2583
Mailing Address - Fax:
Practice Address - Street 1:401 NORTH 27TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223
Practice Address - Country:US
Practice Address - Phone:240-753-2583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health