Healthcare Provider Details

I. General information

NPI: 1497083133
Provider Name (Legal Business Name): DIMITRY GELLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2009
Last Update Date: 11/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 SATURN AVE STE 180
HUNTINGTON PARK CA
90255-4568
US

IV. Provider business mailing address

8160 MANITOBA ST APT 111
PLAYA DEL REY CA
90293-8639
US

V. Phone/Fax

Practice location:
  • Phone: 323-589-5880
  • Fax:
Mailing address:
  • Phone: 323-589-5880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: