Healthcare Provider Details

I. General information

NPI: 1265875413
Provider Name (Legal Business Name): ILIANA LEGORRETA GELLES LMFT 97001
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1693 MISSION DR STE 204
SOLVANG CA
93463-2635
US

IV. Provider business mailing address

PO BOX 1206
BUELLTON CA
93427-1206
US

V. Phone/Fax

Practice location:
  • Phone: 805-350-8862
  • Fax:
Mailing address:
  • Phone: 805-350-8862
  • Fax: 805-350-8862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT97001
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: