Healthcare Provider Details

I. General information

NPI: 1093379307
Provider Name (Legal Business Name): JONATHAN DAVID GELLER MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2019
Last Update Date: 04/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 KINGS HIGHWAY NORTH
WESTPORT CT
06880
US

IV. Provider business mailing address

166 KINGS HIGHWAY NORTH
WESTPORT CT
06880
US

V. Phone/Fax

Practice location:
  • Phone: 203-221-0333
  • Fax:
Mailing address:
  • Phone: 203-221-0333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number001388LCSW
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: