Provider Demographics
NPI:1902291149
Name:ADJIBOLOSOO, SELORM
Entity Type:Individual
Prefix:
First Name:SELORM
Middle Name:
Last Name:ADJIBOLOSOO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9400 RUFFIN CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-5300
Mailing Address - Country:US
Mailing Address - Phone:619-694-8790
Mailing Address - Fax:
Practice Address - Street 1:9400 RUFFIN CT
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-5300
Practice Address - Country:US
Practice Address - Phone:619-694-8790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-04
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103395106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist