Provider Demographics
NPI:1285244335
Name:CONCEPCION, SELENA
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:CONCEPCION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20883 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PNES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-2185
Mailing Address - Country:US
Mailing Address - Phone:954-662-5863
Mailing Address - Fax:
Practice Address - Street 1:2300 W 84TH ST STE 404A
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-5773
Practice Address - Country:US
Practice Address - Phone:561-350-8591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2022-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-129014106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician