Provider Demographics
NPI:1114655081
Name:ESPARZA, SELINA MARIE
Entity Type:Individual
Prefix:
First Name:SELINA
Middle Name:MARIE
Last Name:ESPARZA
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 1:26063 BASE LINE ST SPC 7
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-7061
Mailing Address - Country:US
Mailing Address - Phone:909-693-7866
Mailing Address - Fax:
Practice Address - Street 1:26063 BASE LINE ST SPC 7
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-7061
Practice Address - Country:US
Practice Address - Phone:909-693-7866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty