Healthcare Provider Details

I. General information

NPI: 1629123617
Provider Name (Legal Business Name): WENDY LUDECKE SELEVITCH M.A., PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 10/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 E FOOTHILL BLVD SUITE 102
ARCADIA CA
91006-2361
US

IV. Provider business mailing address

41 E FOOTHILL BLVD SUITE 102
ARCADIA CA
91006-2361
US

V. Phone/Fax

Practice location:
  • Phone: 626-701-4249
  • Fax: 626-737-6034
Mailing address:
  • Phone: 626-701-4249
  • Fax: 626-737-6034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 38430
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 22818
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: