1336161231 NPI number — DR. MANUEL LINCOLN SELYA PH.D. PSYCHOLOGY

Table of content: DR. MANUEL LINCOLN SELYA PH.D. PSYCHOLOGY (NPI 1336161231)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336161231 NPI number — DR. MANUEL LINCOLN SELYA PH.D. PSYCHOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SELYA
Provider First Name:
MANUEL
Provider Middle Name:
LINCOLN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D. PSYCHOLOGY
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SELYA
Provider Other First Name:
EMANUEL
Provider Other Middle Name:
LINCOLN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D. PSYCHOLOGY
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1336161231
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 CRESCENT BAY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGUNA BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92651-1321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-929-1143
Provider Business Mailing Address Fax Number:
949-494-6255

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4199 CAMPUS DR
Provider Second Line Business Practice Location Address:
350
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92612-4684
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-929-1143
Provider Business Practice Location Address Fax Number:
949-494-6255
Provider Enumeration Date:
07/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY 7600 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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