Provider Demographics
NPI:1104300664
Name:SELANDER, ANDREW W (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:W
Last Name:SELANDER
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4209 CUSHMAN RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-6109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6735 VISTAGREEN WAY STE 210
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5654
Practice Address - Country:US
Practice Address - Phone:815-391-3055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490206041041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical