Provider Demographics
NPI:1891439741
Name:FITZGERALD HAMMER, SELENA BREE
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:BREE
Last Name:FITZGERALD HAMMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SELENA
Other - Middle Name:BREE
Other - Last Name:HAMMER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:157 S HOWARD ST STE 310
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-4421
Mailing Address - Country:US
Mailing Address - Phone:509-494-9191
Mailing Address - Fax:
Practice Address - Street 1:3801 UNION DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-6652
Practice Address - Country:US
Practice Address - Phone:509-494-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NERBT-21-193832106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician