Provider Demographics
NPI:1043263635
Name:LINDA S GERONILLA PHD INC
Entity Type:Organization
Organization Name:LINDA S GERONILLA PHD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:GERONILLA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:304-342-2260
Mailing Address - Street 1:92 COOK DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-1003
Mailing Address - Country:US
Mailing Address - Phone:304-342-2260
Mailing Address - Fax:304-344-4522
Practice Address - Street 1:92 COOK DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-1003
Practice Address - Country:US
Practice Address - Phone:304-342-2260
Practice Address - Fax:304-344-4522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV385103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0163217000Medicaid
=========Medicare UPIN
WVCP24261Medicare ID - Type Unspecified