Provider Demographics
NPI:1497083133
Name:GELLER, DIMITRY
Entity Type:Individual
Prefix:
First Name:DIMITRY
Middle Name:
Last Name:GELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8160 MANITOBA ST APT 111
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-8639
Mailing Address - Country:US
Mailing Address - Phone:323-589-5880
Mailing Address - Fax:
Practice Address - Street 1:2680 SATURN AVE STE 180
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4568
Practice Address - Country:US
Practice Address - Phone:323-589-5880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)