Provider Demographics
NPI:1750747838
Name:SELVARAJAH, AMANDA (MAC,LAC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SELVARAJAH
Suffix:
Gender:F
Credentials:MAC,LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 GARDEN CTR
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-1730
Mailing Address - Country:US
Mailing Address - Phone:303-305-9325
Mailing Address - Fax:
Practice Address - Street 1:18 GARDEN CTR
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-1730
Practice Address - Country:US
Practice Address - Phone:303-305-9325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU0001964171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist