Provider Demographics
NPI:1447968110
Name:SELWA, KEITH DOUGLAS
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:DOUGLAS
Last Name:SELWA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4023 MARINE AVE
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-1840
Mailing Address - Country:US
Mailing Address - Phone:310-675-9555
Mailing Address - Fax:310-263-1909
Practice Address - Street 1:4023 MARINE AVE
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-1840
Practice Address - Country:US
Practice Address - Phone:310-675-9555
Practice Address - Fax:310-263-1909
Is Sole Proprietor?:No
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13698101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)