Healthcare Provider Details

I. General information

NPI: 1144201070
Provider Name (Legal Business Name): SAMUEL TYLER SELEKMAN LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3733 PARK EAST DR #102
BEACHWOOD OH
44122
US

IV. Provider business mailing address

160 FOX HOLLOW DR #207
MAYFIELD HEIGHTS OH
44124
US

V. Phone/Fax

Practice location:
  • Phone: 216-401-3472
  • Fax: 216-292-3291
Mailing address:
  • Phone: 216-401-3472
  • Fax: 216-292-3291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI 0003651
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: