Provider Demographics
NPI:1861787079
Name:GELLER, TINA ROBINSON (MPT)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:ROBINSON
Last Name:GELLER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:24630 WASHINGTON AVE
Mailing Address - Street 2:200
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6177
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:15200 W SUNSET BLVD
Practice Address - Street 2:111
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-3619
Practice Address - Country:US
Practice Address - Phone:310-573-9340
Practice Address - Fax:310-573-9328
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 36921225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT369210OtherBLUE SHIELD OF CALIFORNIA
CAFO571ZMedicare PIN