Basic Information
| Provider Information | |||||||||
| NPI: | 1235508052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CELLI | ||||||||
| FirstName: | MIKAELA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 ELM ST STE 212 | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940703070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503502570 | ||||||||
| FaxNumber: | 4082592273 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 ELM ST STE 212 | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940703070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503502570 | ||||||||
| FaxNumber: | 6505719750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2015 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ASW67072 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 92894 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 92894 | 01 | CA | BOARD OF BEHAVIORAL SCIENCES | OTHER |