Provider Demographics
NPI:1558992123
Name:SMITH, SELAH JOY (LPC)
Entity Type:Individual
Prefix:
First Name:SELAH
Middle Name:JOY
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:SELAH
Other - Middle Name:JOY
Other - Last Name:MCMATH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1750 MISSISSIPPI BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-4774
Mailing Address - Country:US
Mailing Address - Phone:918-408-2687
Mailing Address - Fax:
Practice Address - Street 1:5861 CEDAR LAKE RD S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1653
Practice Address - Country:US
Practice Address - Phone:612-202-8703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2020-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN509827101YS0200X
MN02267101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty