Provider Demographics
NPI:1629845169
Name:AINZUAIN, SELENA M (LCSWA)
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:M
Last Name:AINZUAIN
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4555 OGBURN AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-2726
Practice Address - Country:US
Practice Address - Phone:336-703-4273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-05
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0199041041C0700X
RICSW031241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical