Healthcare Provider Details

I. General information

NPI: 1497039648
Provider Name (Legal Business Name): MS. SELINA STAR BROCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2011
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

942 S ATLANTIC BLVD
LOS ANGELES CA
90022-4004
US

IV. Provider business mailing address

3670 MAINE AVE
BALDWIN PARK CA
91706-5231
US

V. Phone/Fax

Practice location:
  • Phone: 323-263-9700
  • Fax: 323-263-8042
Mailing address:
  • Phone: 626-322-7041
  • Fax: 323-263-8042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRW4272
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: