Provider Demographics
NPI:1568236792
Name:ACOSTA, SELENE
Entity Type:Individual
Prefix:
First Name:SELENE
Middle Name:
Last Name:ACOSTA
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:PO BOX 390959
Mailing Address - Street 2:
Mailing Address - City:ANZA
Mailing Address - State:CA
Mailing Address - Zip Code:92539-0959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:81557 DR CARREON BLVD
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5517
Practice Address - Country:US
Practice Address - Phone:760-391-6999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8187101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health