Provider Demographics
NPI:1619628690
Name:MANIATES-SELVIN, SIERRA (CT)
Entity Type:Individual
Prefix:
First Name:SIERRA
Middle Name:
Last Name:MANIATES-SELVIN
Suffix:
Gender:F
Credentials:CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2622 HACKBERRY ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-2122
Mailing Address - Country:US
Mailing Address - Phone:217-502-3561
Mailing Address - Fax:
Practice Address - Street 1:4030 MOUNT CARMEL TOBASCO RD STE 102
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45255-3408
Practice Address - Country:US
Practice Address - Phone:513-488-7161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2103654101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health