Provider Demographics
NPI:1588114383
Name:SELF, SALLY (MA LPC)
Entity type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:
Last Name:SELF
Suffix:
Gender:F
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4193 US HIGHWAY 11
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35146-7332
Mailing Address - Country:US
Mailing Address - Phone:205-531-6896
Mailing Address - Fax:
Practice Address - Street 1:4193 US HIGHWAY 11
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:AL
Practice Address - Zip Code:35146-7332
Practice Address - Country:US
Practice Address - Phone:205-531-6896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3614101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional