Provider Demographics
NPI:1316539067
Name:LAURA GELLER
Entity Type:Organization
Organization Name:LAURA GELLER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:GELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-230-6121
Mailing Address - Street 1:171 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:OBERLIN
Mailing Address - State:OH
Mailing Address - Zip Code:44074-1507
Mailing Address - Country:US
Mailing Address - Phone:440-230-6121
Mailing Address - Fax:
Practice Address - Street 1:171 FOREST ST
Practice Address - Street 2:
Practice Address - City:OBERLIN
Practice Address - State:OH
Practice Address - Zip Code:44074-1507
Practice Address - Country:US
Practice Address - Phone:440-230-6121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-04
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0413334Medicaid