Provider Demographics
NPI:1336656644
Name:SELDON, THERESA R (DDP)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:R
Last Name:SELDON
Suffix:
Gender:F
Credentials:DDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 COLLETT AVE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-4809
Mailing Address - Country:US
Mailing Address - Phone:678-751-8065
Mailing Address - Fax:770-944-0415
Practice Address - Street 1:440 COLLETT AVE
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-4809
Practice Address - Country:US
Practice Address - Phone:678-751-8065
Practice Address - Fax:770-944-0415
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty