Provider Demographics
NPI:1235672106
Name:SELOVER, JEREMY THOMAS (LGSW)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:THOMAS
Last Name:SELOVER
Suffix:
Gender:M
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 IMLA ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-2807
Mailing Address - Country:US
Mailing Address - Phone:313-617-1822
Mailing Address - Fax:
Practice Address - Street 1:1012 NORTH POINT RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-3338
Practice Address - Country:US
Practice Address - Phone:443-216-4800
Practice Address - Fax:443-216-4801
Is Sole Proprietor?:No
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD217021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical