=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427678234
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAYNA CELCEV AT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2020
-----------------------------------------------------
Last Update Date | 04/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2799 W GRAND BLVD
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48202-2608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-916-2600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50340 BURLWOOD DR
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48047-3732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-789-1166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 2601001139
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------