Provider Demographics
NPI:1225239015
Name:PLUMMER, SELENA SANDRA (MED)
Entity Type:Individual
Prefix:MRS
First Name:SELENA
Middle Name:SANDRA
Last Name:PLUMMER
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 SE 53RD ST
Mailing Address - Street 2:
Mailing Address - City:KEYSTONE HEIGHTS
Mailing Address - State:FL
Mailing Address - Zip Code:32656-6356
Mailing Address - Country:US
Mailing Address - Phone:904-364-6381
Mailing Address - Fax:
Practice Address - Street 1:765 SE 53RD ST
Practice Address - Street 2:
Practice Address - City:KEYSTONE HEIGHTS
Practice Address - State:FL
Practice Address - Zip Code:32656-6356
Practice Address - Country:US
Practice Address - Phone:904-364-6381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH3638101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health