Healthcare Provider Details

I. General information

NPI: 1700624582
Provider Name (Legal Business Name): CELCILIA M CIPRIANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2024
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 W CUSTER AVE
PONTIAC IL
61764-1067
US

IV. Provider business mailing address

PO BOX 768
PONTIAC IL
61764-0768
US

V. Phone/Fax

Practice location:
  • Phone: 815-844-6109
  • Fax: 815-844-3561
Mailing address:
  • Phone: 815-844-6109
  • Fax: 815-844-3561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: