Healthcare Provider Details

I. General information

NPI: 1003344128
Provider Name (Legal Business Name): SELAH COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

983 SPAULDING AVE SE
ADA MI
49301-3701
US

IV. Provider business mailing address

983 SPAULDING AVE SE
ADA MI
49301-3701
US

V. Phone/Fax

Practice location:
  • Phone: 616-466-4790
  • Fax:
Mailing address:
  • Phone: 616-466-4790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801093737
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: AMANDA I WORST
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LMSW
Phone: 616-466-4790