Healthcare Provider Details

I. General information

NPI: 1336161231
Provider Name (Legal Business Name): MANUEL LINCOLN SELYA PH.D. PSYCHOLOGY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: EMANUEL LINCOLN SELYA PH.D. PSYCHOLOGY

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4199 CAMPUS DR 350
IRVINE CA
92612-4684
US

IV. Provider business mailing address

120 CRESCENT BAY DR
LAGUNA BEACH CA
92651-1321
US

V. Phone/Fax

Practice location:
  • Phone: 949-929-1143
  • Fax: 949-494-6255
Mailing address:
  • Phone: 949-929-1143
  • Fax: 949-494-6255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 7600
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: