Provider Demographics
NPI:1023737624
Name:SELPH, MARTHA LOUSIA (LMSW)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:LOUSIA
Last Name:SELPH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 HAW CREEK CIR STE 403
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-6567
Mailing Address - Country:US
Mailing Address - Phone:770-940-9679
Mailing Address - Fax:
Practice Address - Street 1:1435 HAW CREEK CIR STE 403
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6567
Practice Address - Country:US
Practice Address - Phone:770-940-9679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW010890104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial Worker