Provider Demographics
NPI:1477053684
Name:SELDERS, JUSTIN D
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:D
Last Name:SELDERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9423 DORCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70814-2840
Mailing Address - Country:US
Mailing Address - Phone:225-573-7899
Mailing Address - Fax:
Practice Address - Street 1:9423 DORCHESTER DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70814-2840
Practice Address - Country:US
Practice Address - Phone:225-573-7899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA00000Medicaid