Provider Demographics
NPI:1083158588
Name:SELTMAN, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:SELTMAN
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 1:4511 N HIMES AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7074
Mailing Address - Country:US
Mailing Address - Phone:813-417-7879
Mailing Address - Fax:813-422-7954
Practice Address - Street 1:4511 N HIMES AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7074
Practice Address - Country:US
Practice Address - Phone:813-417-7879
Practice Address - Fax:813-422-7954
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL017423100103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst