Provider Demographics
NPI:1356124234
Name:MANDA SELVA, LICENSED CLINICAL SOCIAL WORKER, INC
Entity type:Organization
Organization Name:MANDA SELVA, LICENSED CLINICAL SOCIAL WORKER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MADHULLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SELVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-230-9565
Mailing Address - Street 1:2646 APPIAN WAY
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2242
Mailing Address - Country:US
Mailing Address - Phone:510-230-9565
Mailing Address - Fax:
Practice Address - Street 1:631 LA PALOMA RD
Practice Address - Street 2:
Practice Address - City:EL SOBRANTE
Practice Address - State:CA
Practice Address - Zip Code:94803-1735
Practice Address - Country:US
Practice Address - Phone:510-230-9565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-15
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty