Provider Demographics
NPI:1629492962
Name:SELBY-BROUCHET, KRISTINA DANIELLE
Entity Type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:DANIELLE
Last Name:SELBY-BROUCHET
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 1:2121 MOUNTAIN RAIL DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-3124
Mailing Address - Country:US
Mailing Address - Phone:702-715-4229
Mailing Address - Fax:
Practice Address - Street 1:2121 MOUNTAIN RAIL DR
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084-3124
Practice Address - Country:US
Practice Address - Phone:702-715-4229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health