Healthcare Provider Details

I. General information

NPI: 1578552881
Provider Name (Legal Business Name): ELEANOR GELLER BOTHA M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELEANOR DENISE GELLER M.S.

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2165 N DECATUR RD OF HUMAN GENETICS/DIVISION OF MEDICAL GENETICS
DECATUR GA
30033-5307
US

IV. Provider business mailing address

2165 N DECATUR RD
DECATUR GA
30033-5307
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-8517
  • Fax: 404-778-8562
Mailing address:
  • Phone: 404-778-8517
  • Fax: 404-778-8562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744R1102X
TaxonomyResearch Study Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: