Provider Demographics
NPI:1598054900
Name:SELM, LEO JOSEPH III (PSY D)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:JOSEPH
Last Name:SELM
Suffix:III
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 268
Mailing Address - Street 2:
Mailing Address - City:PITMAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08071
Mailing Address - Country:US
Mailing Address - Phone:609-922-0980
Mailing Address - Fax:
Practice Address - Street 1:BOX 268
Practice Address - Street 2:
Practice Address - City:PITMAN
Practice Address - State:NJ
Practice Address - Zip Code:08071
Practice Address - Country:US
Practice Address - Phone:609-922-0980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-06
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100450200103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist