Healthcare Provider Details

I. General information

NPI: 1396715603
Provider Name (Legal Business Name): GLORIA S GELEYNSE M.ED., LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 S ACADEMY AVE SUITE F
EAGLE ID
83616-6541
US

IV. Provider business mailing address

136 S ACADEMY AVE SUITE F
EAGLE ID
83616-6541
US

V. Phone/Fax

Practice location:
  • Phone: 208-939-1133
  • Fax: 208-939-9110
Mailing address:
  • Phone: 208-939-1133
  • Fax: 208-939-9110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-31
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: