Provider Demographics
NPI:1407555816
Name:WOLDEMARIAM, SELAM UKBAMARIAM (RADT)
Entity Type:Individual
Prefix:
First Name:SELAM
Middle Name:UKBAMARIAM
Last Name:WOLDEMARIAM
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17821 LASSEN ST APT 221
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-4711
Mailing Address - Country:US
Mailing Address - Phone:619-627-4438
Mailing Address - Fax:
Practice Address - Street 1:5554 RESEDA BLVD
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-2200
Practice Address - Country:US
Practice Address - Phone:818-705-5522
Practice Address - Fax:888-882-7527
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician