=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457900235
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROL GELLER, SLP-C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2019
-----------------------------------------------------
Last Update Date | 09/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 298 MEDEA WAY
-----------------------------------------------------
City | CENTRAL ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11722-4540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-757-4289
-----------------------------------------------------
Fax | 631-757-6313
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 298 MEDEA WAY
-----------------------------------------------------
City | CENTRAL ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11722-4540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-757-4289
-----------------------------------------------------
Fax | 631-757-6313
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CAROL GELLER
-----------------------------------------------------
Credential | SLP
-----------------------------------------------------
Telephone | 631-757-4289
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------