Provider Demographics
NPI:1700867181
Name:SELISKAR, JOHANNA M (LISW)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:M
Last Name:SELISKAR
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:M
Other - Last Name:SELISKAR-DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LISW
Mailing Address - Street 1:11 PINE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-5534
Mailing Address - Country:US
Mailing Address - Phone:406-202-0608
Mailing Address - Fax:
Practice Address - Street 1:4815 N ASSEMBLY ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-6185
Practice Address - Country:US
Practice Address - Phone:509-434-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI056281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM02429276Medicaid
NM02429276Medicaid