Provider Demographics
NPI:1306298112
Name:TELLER-HOLT, GISELLE (PH D)
Entity type:Individual
Prefix:DR
First Name:GISELLE
Middle Name:
Last Name:TELLER-HOLT
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 E TELEGRAPH RD SPC 72
Mailing Address - Street 2:
Mailing Address - City:FILLMORE
Mailing Address - State:CA
Mailing Address - Zip Code:93015-2149
Mailing Address - Country:US
Mailing Address - Phone:805-208-2074
Mailing Address - Fax:
Practice Address - Street 1:250 E TELEGRAPH RD SPC 72
Practice Address - Street 2:
Practice Address - City:FILLMORE
Practice Address - State:CA
Practice Address - Zip Code:93015-2149
Practice Address - Country:US
Practice Address - Phone:805-208-2074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT111041101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health