Provider Demographics
NPI:1194810515
Name:HERBST, SELMA (MSSW, ACSW, LCSW)
Entity type:Individual
Prefix:
First Name:SELMA
Middle Name:
Last Name:HERBST
Suffix:
Gender:F
Credentials:MSSW, ACSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3657 VICKIANN ST.
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593
Mailing Address - Country:US
Mailing Address - Phone:608-836-9139
Mailing Address - Fax:
Practice Address - Street 1:3657 VICKIANN ST
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593
Practice Address - Country:US
Practice Address - Phone:608-836-9139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2448-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39243300Medicaid