Healthcare Provider Details

I. General information

NPI: 1194478487
Provider Name (Legal Business Name): ELIZABETH NAOMI CELESTINE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2022
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2152 N ELDER AVE
HUACHUCA CITY AZ
85616-8124
US

IV. Provider business mailing address

2152 N ELDER AVE
HUACHUCA CITY AZ
85616-8124
US

V. Phone/Fax

Practice location:
  • Phone: 520-442-8947
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberBH6658
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: