Provider Demographics
NPI:1376852814
Name:GELLER, JESSE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:
Last Name:GELLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:389 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-2301
Mailing Address - Country:US
Mailing Address - Phone:203-785-8553
Mailing Address - Fax:203-562-6355
Practice Address - Street 1:389 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-2301
Practice Address - Country:US
Practice Address - Phone:203-785-8553
Practice Address - Fax:203-562-6355
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1152103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT$$$$$$$$$OtherSOCIAL SECURITY #