Provider Demographics
NPI:1932403060
Name:SELVA, MICHEL (PSYD)
Entity Type:Individual
Prefix:
First Name:MICHEL
Middle Name:
Last Name:SELVA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MIFFLIN PL
Mailing Address - Street 2:STE 260
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-4947
Mailing Address - Country:US
Mailing Address - Phone:617-605-7429
Mailing Address - Fax:
Practice Address - Street 1:1 MIFFLIN PL
Practice Address - Street 2:STE 260
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4947
Practice Address - Country:US
Practice Address - Phone:617-605-7429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-04
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7483103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS300135953Medicare PIN