Provider Demographics
NPI:1063645794
Name:SELASSIE, RUTH B
Entity Type:Individual
Prefix:MS
First Name:RUTH
Middle Name:B
Last Name:SELASSIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18129 DORSET CT
Mailing Address - Street 2:
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748-5148
Mailing Address - Country:US
Mailing Address - Phone:562-544-3192
Mailing Address - Fax:
Practice Address - Street 1:5005 TEXAS ST STE 203
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3723
Practice Address - Country:US
Practice Address - Phone:619-692-0727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD4842943104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker