MEDICARE: MS. LAURA JANE SELDERS MA, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1710293287
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAURA JANE SELDERS MA, PC

Provider Business Mailing Address
First Line	:	9051 COUNTY ROAD 203
Second Line	:
City	:	VAN BUREN
State	:	OH
Zip	:	45889
Country	:	US
Telephone Number	:	419-306-3017
Fax Number	:

Provider Business Practice Location Address
First Line	:	701 JEFFERSON AVE STE 301
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43604-6957
Country	:	US
Telephone Number	:	419-321-6455
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2010
Last Update Date	:	05/19/2011

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