Provider Demographics
NPI:1467204537
Name:AUSTIN, SELENA N
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:N
Last Name:AUSTIN
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 1:215 RED COACH DR
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-8307
Mailing Address - Country:US
Mailing Address - Phone:574-387-4313
Mailing Address - Fax:574-204-2868
Practice Address - Street 1:614 N 6TH ST STE B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5314
Practice Address - Country:US
Practice Address - Phone:574-387-4313
Practice Address - Fax:574-204-2868
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician