Provider Demographics
NPI:1679852966
Name:MERSEREAU, SELENE
Entity Type:Individual
Prefix:
First Name:SELENE
Middle Name:
Last Name:MERSEREAU
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 1:970 N KALAHEO AVE
Mailing Address - Street 2:A310B
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-1866
Mailing Address - Country:US
Mailing Address - Phone:808-782-3110
Mailing Address - Fax:808-263-0207
Practice Address - Street 1:970 N KALAHEO AVE
Practice Address - Street 2:A310B
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-1866
Practice Address - Country:US
Practice Address - Phone:808-782-3110
Practice Address - Fax:808-263-0207
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI263106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist