Healthcare Provider Details

I. General information

NPI: 1922174879
Provider Name (Legal Business Name): SUNDHYA P GELLES MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 04/01/2021
Certification Date: 04/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13160 COUNTY RD. 3610
ST. JAMES MO
65559
US

IV. Provider business mailing address

1650 COCHRANE CIR UNIT MEDDAC
FT CARSON CO
80913-4604
US

V. Phone/Fax

Practice location:
  • Phone: 573-265-0059
  • Fax:
Mailing address:
  • Phone: 719-526-6521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number004522
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier497944025
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: