Provider Demographics
NPI:1194207050
Name:MOREFIELD, SELENA
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:MOREFIELD
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 1:1739 HIDDEN TRL
Mailing Address - Street 2:
Mailing Address - City:MAYER
Mailing Address - State:MN
Mailing Address - Zip Code:55360-4543
Mailing Address - Country:US
Mailing Address - Phone:952-388-4774
Mailing Address - Fax:
Practice Address - Street 1:113 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387
Practice Address - Country:US
Practice Address - Phone:855-454-2463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health