Provider Demographics
NPI:1699546440
Name:MESA WAA GII, LLC
Entity type:Organization
Organization Name:MESA WAA GII, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SELBY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:765-231-5672
Mailing Address - Street 1:115 N GREEN ST STE 102
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-1708
Mailing Address - Country:US
Mailing Address - Phone:765-366-2644
Mailing Address - Fax:
Practice Address - Street 1:115 N GREEN ST STE 102
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-1708
Practice Address - Country:US
Practice Address - Phone:765-366-2644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-10
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty