Healthcare Provider Details

I. General information

NPI: 1972902740
Provider Name (Legal Business Name): CELESTA HARRIS PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CELESTA TAYLOR

II. Dates (important events)

Enumeration Date: 08/18/2014
Last Update Date: 08/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11010 DOMAIN DR #11331
AUSTIN TX
78758-7711
US

IV. Provider business mailing address

11010 DOMAIN DR #11331
AUSTIN TX
78758-7711
US

V. Phone/Fax

Practice location:
  • Phone: 817-707-7637
  • Fax:
Mailing address:
  • Phone: 817-707-7637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number36729
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: