Provider Demographics
NPI:1598111320
Name:SELFRIDGE, ALICIA
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:SELFRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:
Other - Last Name:ESTORGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 20970
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7020
Mailing Address - Country:US
Mailing Address - Phone:307-286-0544
Mailing Address - Fax:
Practice Address - Street 1:5416 EDUCATION DR
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4094
Practice Address - Country:US
Practice Address - Phone:307-778-3675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-13531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical