Provider Demographics
NPI:1619379971
Name:HERCINOVIC, SELMA
Entity Type:Individual
Prefix:
First Name:SELMA
Middle Name:
Last Name:HERCINOVIC
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 1:110 S 800 E
Mailing Address - Street 2:406
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-4118
Mailing Address - Country:US
Mailing Address - Phone:801-598-1096
Mailing Address - Fax:
Practice Address - Street 1:630 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4908
Practice Address - Country:US
Practice Address - Phone:801-299-3780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6851568-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical