Provider Demographics
NPI:1588938427
Name:MEHTA, SELENE LEELAM
Entity type:Individual
Prefix:MS
First Name:SELENE
Middle Name:LEELAM
Last Name:MEHTA
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 1:628 N CHARTER HALL DR
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-8678
Mailing Address - Country:US
Mailing Address - Phone:847-212-9337
Mailing Address - Fax:
Practice Address - Street 1:721 S QUENTIN RD
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-6778
Practice Address - Country:US
Practice Address - Phone:847-359-7490
Practice Address - Fax:847-359-7525
Is Sole Proprietor?:No
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490085441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical