Provider Demographics
NPI:1588044887
Name:SELASSIE, HAILE
Entity Type:Individual
Prefix:
First Name:HAILE
Middle Name:
Last Name:SELASSIE
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 1:138 S COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10553-1337
Mailing Address - Country:US
Mailing Address - Phone:646-353-8919
Mailing Address - Fax:914-663-7203
Practice Address - Street 1:138 S COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10553-1337
Practice Address - Country:US
Practice Address - Phone:914-663-7201
Practice Address - Fax:914-663-7203
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP94860101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health