Provider Demographics
NPI:1073079497
Name:SELMON, ELECIA A
Entity Type:Individual
Prefix:
First Name:ELECIA
Middle Name:A
Last Name:SELMON
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 1:126 WOODED CREEK DR
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75154-6234
Mailing Address - Country:US
Mailing Address - Phone:972-935-1247
Mailing Address - Fax:
Practice Address - Street 1:1545 W MOCKINGBIRD LN STE 4000
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-5014
Practice Address - Country:US
Practice Address - Phone:972-935-1247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator