Provider Demographics
NPI:1437518396
Name:MADUFORO, SELINA S (LCSW-C)
Entity Type:Individual
Prefix:
First Name:SELINA
Middle Name:S
Last Name:MADUFORO
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 S CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-5730
Mailing Address - Country:US
Mailing Address - Phone:301-768-6180
Mailing Address - Fax:
Practice Address - Street 1:11341 LAURELWALK DR
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-3006
Practice Address - Country:US
Practice Address - Phone:301-768-6180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-19
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13803104100000X, 1041C0700X
DCLC500799371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker