Provider Demographics
NPI:1609332501
Name:KIDANE, SELAM (LCSW)
Entity type:Individual
Prefix:
First Name:SELAM
Middle Name:
Last Name:KIDANE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 HUFF AVE APT 12
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-3010
Mailing Address - Country:US
Mailing Address - Phone:408-930-5280
Mailing Address - Fax:
Practice Address - Street 1:777 LAWRENCE EXPY
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95051-5195
Practice Address - Country:US
Practice Address - Phone:408-851-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA863011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical