Provider Demographics
NPI:1366053563
Name:COBURN, SELENA E
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:E
Last Name:COBURN
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 1:4424 GAINES RANCH LOOP APT 1434
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-6540
Mailing Address - Country:US
Mailing Address - Phone:406-781-7251
Mailing Address - Fax:
Practice Address - Street 1:4424 GAINES RANCH LOOP APT 1434
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-6540
Practice Address - Country:US
Practice Address - Phone:406-781-7251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11902-MH-CC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health