Healthcare Provider Details

I. General information

NPI: 1811522444
Provider Name (Legal Business Name): NICOLE SELIGMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 S 4TH ST STE 471
PHILADELPHIA PA
19147-1582
US

IV. Provider business mailing address

2921 HAVERFORD RD
ARDMORE PA
19003-1816
US

V. Phone/Fax

Practice location:
  • Phone: 267-861-3685
  • Fax: 215-965-1513
Mailing address:
  • Phone: 610-996-8439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS019896
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: