Healthcare Provider Details

I. General information

NPI: 1295224053
Provider Name (Legal Business Name): MRS. LAURA ANNE GELLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 05/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 HORATIO BLVD
BUFFALO GROVE IL
60089-6416
US

IV. Provider business mailing address

2425 RIVERWOODS RD
LINCOLNSHIRE IL
60069-3249
US

V. Phone/Fax

Practice location:
  • Phone: 847-777-1189
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146.008646
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: