Provider Demographics
NPI:1215110747
Name:SELHA, MYKE (LISW)
Entity type:Individual
Prefix:
First Name:MYKE
Middle Name:
Last Name:SELHA
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3408 WOODLAND AVE
Mailing Address - Street 2:SUITE 305M
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-6506
Mailing Address - Country:US
Mailing Address - Phone:515-996-0360
Mailing Address - Fax:515-243-5823
Practice Address - Street 1:3408 WOODLAND AVE
Practice Address - Street 2:SUITE 305M
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-6506
Practice Address - Country:US
Practice Address - Phone:515-996-0360
Practice Address - Fax:515-243-5823
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA65381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical