Provider Demographics
NPI:1740626928
Name:SELMA DALLAS PREVENTION COLLABORATIVE
Entity type:Organization
Organization Name:SELMA DALLAS PREVENTION COLLABORATIVE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:COLEY
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHESTNUT
Authorized Official - Suffix:SR
Authorized Official - Credentials:MS, MMIN
Authorized Official - Phone:334-526-2500
Mailing Address - Street 1:PO BOX 525
Mailing Address - Street 2:1 BELL ROAD
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36702-0525
Mailing Address - Country:US
Mailing Address - Phone:334-526-2500
Mailing Address - Fax:334-526-2502
Practice Address - Street 1:1 BELL RD
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-6703
Practice Address - Country:US
Practice Address - Phone:334-526-2500
Practice Address - Fax:334-526-2502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency