Healthcare Provider Details

I. General information

NPI: 1033675145
Provider Name (Legal Business Name): MARK A CELIO PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2019
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 S MAIN ST
PROVIDENCE RI
02903-2905
US

IV. Provider business mailing address

6 FENWICK RD
RIVERSIDE RI
02915-1420
US

V. Phone/Fax

Practice location:
  • Phone: 401-863-6662
  • Fax:
Mailing address:
  • Phone: 401-497-7884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS01682
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: