Provider Demographics
NPI:1144201070
Name:SELEKMAN, SAMUEL TYLER (LISW)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:TYLER
Last Name:SELEKMAN
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 FOX HOLLOW DR
Mailing Address - Street 2:#207
Mailing Address - City:MAYFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124
Mailing Address - Country:US
Mailing Address - Phone:216-401-3472
Mailing Address - Fax:216-292-3291
Practice Address - Street 1:3733 PARK EAST DR
Practice Address - Street 2:#102
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122
Practice Address - Country:US
Practice Address - Phone:216-401-3472
Practice Address - Fax:216-292-3291
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 0003651104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSESW00331Medicare ID - Type Unspecified