Healthcare Provider Details

I. General information

NPI: 1598054900
Provider Name (Legal Business Name): LEO JOSEPH SELM III PSY. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 12/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BOX 268
PITMAN NJ
08071
US

IV. Provider business mailing address

BOX 268
PITMAN NJ
08071
US

V. Phone/Fax

Practice location:
  • Phone: 609-922-0980
  • Fax:
Mailing address:
  • Phone: 609-922-0980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number35S100450200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: