Healthcare Provider Details

I. General information

NPI: 1316944432
Provider Name (Legal Business Name): SELENA WISMAN LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 W SPRING ST
NEW ALBANY IN
47150
US

IV. Provider business mailing address

9800 TUCSON CT
LOUISVILLE KY
40223
US

V. Phone/Fax

Practice location:
  • Phone: 812-206-3291
  • Fax: 812-206-3296
Mailing address:
  • Phone: 502-426-9747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35001423A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0417
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: