Basic Information
| Provider Information | |||||||||
| NPI: | 1093863706 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GHELLER | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COON | ||||||||
| OtherFirstName: | GINA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5909 WEST LOOP SOUTH | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | BELLAIR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774012417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2818138330 | ||||||||
| FaxNumber: | 7134637181 | ||||||||
| Practice Location | |||||||||
| Address1: | 5909 WEST LOOP S | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | BELLAIRE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774012402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2818138330 | ||||||||
| FaxNumber: | 7134637181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 12/22/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 30588 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 103756601 | 05 | TX | MEDICAID |