Healthcare Provider Details

I. General information

NPI: 1528128071
Provider Name (Legal Business Name): MARILYN IPPOLITO GELLER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 FRONT STREET SUITE C
VESTAL NY
13850
US

IV. Provider business mailing address

200 FRONT STREET SUITE C
VESTAL NY
13850
US

V. Phone/Fax

Practice location:
  • Phone: 607-754-2313
  • Fax: 607-754-6926
Mailing address:
  • Phone: 607-754-2313
  • Fax: 607-754-6926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0068391
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: