Provider Demographics
NPI:1184753634
Name:GELLER, TARA LYNNE (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LYNNE
Last Name:GELLER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 TERRY DR
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6778
Mailing Address - Country:US
Mailing Address - Phone:410-960-3291
Mailing Address - Fax:
Practice Address - Street 1:4605 TERRY DR
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-6778
Practice Address - Country:US
Practice Address - Phone:410-960-3291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02536235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD419800000Medicaid