=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477218295
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SELAH PROFESSIONAL COUNSELORS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2021
-----------------------------------------------------
Last Update Date | 11/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7501 LEMONT RD STE 16
-----------------------------------------------------
City | WOODRIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60517-2658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-343-9077
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11946 W HEATHER GLEN LN
-----------------------------------------------------
City | MANHATTAN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60442-9808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARIJA LAMAS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 815-953-5039
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------