Provider Demographics
NPI:1891734414
Name:SELTENREICH, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:SELTENREICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 BROADLEAF DR
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-5719
Mailing Address - Country:US
Mailing Address - Phone:518-859-3951
Mailing Address - Fax:518-373-5925
Practice Address - Street 1:21 BROADLEAF DR
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-5719
Practice Address - Country:US
Practice Address - Phone:518-859-3951
Practice Address - Fax:518-373-5925
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010817-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01939528Medicaid
NY010817-1OtherLICENSE REGISTRATION CERT