Provider Demographics
NPI:1780738906
Name:MARTIN, SELENA (BS)
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 COFFMAN ST STE 300
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-5450
Mailing Address - Country:US
Mailing Address - Phone:303-245-4415
Mailing Address - Fax:
Practice Address - Street 1:529 COFFMAN ST STE 300
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-5450
Practice Address - Country:US
Practice Address - Phone:303-245-4415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health