Healthcare Provider Details

I. General information

NPI: 1407793227
Provider Name (Legal Business Name): SELENA SANDRUCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10005 OLD COLUMBIA RD STE L260
COLUMBIA MD
21046-1722
US

IV. Provider business mailing address

10005 OLD COLUMBIA RD STE L260
COLUMBIA MD
21046-1722
US

V. Phone/Fax

Practice location:
  • Phone: 443-259-0400
  • Fax: 443-259-0044
Mailing address:
  • Phone: 443-259-0400
  • Fax: 443-259-0044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License NumberATC429
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: