Healthcare Provider Details

I. General information

NPI: 1699041335
Provider Name (Legal Business Name): SELENA WHITTLE PHD, MS, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3126 NW BUTTERCUP DR
CORVALLIS OR
97330-3380
US

IV. Provider business mailing address

3126 NW BUTTERCUP DR
CORVALLIS OR
97330-3380
US

V. Phone/Fax

Practice location:
  • Phone: 503-908-1550
  • Fax:
Mailing address:
  • Phone: 503-908-1550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberC2845
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: