Healthcare Provider Details

I. General information

NPI: 1023656485
Provider Name (Legal Business Name): TIA JUSTINE GELLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2019
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SHELTON MCMURPHEY BLVD
EUGENE OR
97401-4928
US

IV. Provider business mailing address

355 MARCHE CHASE DR APT 200
EUGENE OR
97401-8876
US

V. Phone/Fax

Practice location:
  • Phone: 541-485-2711
  • Fax:
Mailing address:
  • Phone: 231-735-6241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: