Provider Demographics
NPI:1457396137
Name:SELBY, GRETCHEN LOUISE (LMSW)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:LOUISE
Last Name:SELBY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 15TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-3000
Mailing Address - Country:US
Mailing Address - Phone:505-662-3264
Mailing Address - Fax:505-662-9707
Practice Address - Street 1:1505 15TH ST
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-3000
Practice Address - Country:US
Practice Address - Phone:505-662-3264
Practice Address - Fax:505-662-9707
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-057777104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker