1093863706 NPI number — MS. GINA MARIE GHELLER LCSW

Table of content: MS. GINA MARIE GHELLER LCSW (NPI 1093863706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093863706 NPI number — MS. GINA MARIE GHELLER LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GHELLER
Provider First Name:
GINA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COON
Provider Other First Name:
GINA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093863706
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5909 WEST LOOP SOUTH
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
BELLAIR
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77401-2417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-813-8330
Provider Business Mailing Address Fax Number:
713-463-7181

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5909 WEST LOOP S
Provider Second Line Business Practice Location Address:
SUITE 600
Provider Business Practice Location Address City Name:
BELLAIRE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77401-2402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-813-8330
Provider Business Practice Location Address Fax Number:
713-463-7181
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  30588 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 103756601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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