Provider Demographics
NPI:1275185985
Name:SELAN, MANA
Entity Type:Individual
Prefix:
First Name:MANA
Middle Name:
Last Name:SELAN
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 1:2500 SAWMILL RD APT 1115
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 SAWMILL RD APT 1115
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5690
Practice Address - Country:US
Practice Address - Phone:505-209-5467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician