Provider Demographics
NPI:1710616818
Name:SELEXANT, VIERGE AUDREY
Entity Type:Individual
Prefix:
First Name:VIERGE
Middle Name:AUDREY
Last Name:SELEXANT
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 1:1924 DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-4046
Mailing Address - Country:US
Mailing Address - Phone:321-615-2171
Mailing Address - Fax:
Practice Address - Street 1:1924 DAIRY RD
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-4046
Practice Address - Country:US
Practice Address - Phone:321-615-2171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health