Provider Demographics
NPI:1235217613
Name:SELENE, WENDY LYNN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:LYNN
Last Name:SELENE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 MAPLE AVE
Mailing Address - Street 2:SUITE 1206
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3667
Mailing Address - Country:US
Mailing Address - Phone:847-328-4788
Mailing Address - Fax:847-328-4788
Practice Address - Street 1:1640 MAPLE AVE
Practice Address - Street 2:SUITE 1206
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3667
Practice Address - Country:US
Practice Address - Phone:847-328-4788
Practice Address - Fax:847-328-4788
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016-73450OtherBLUE CROSS AND BLUE SHIEL