Provider Demographics
NPI:1871357848
Name:SELMON-VASSER, JAMES (PSYD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:SELMON-VASSER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 201213
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-6213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 FEDERAL DR
Practice Address - Street 2:
Practice Address - City:FORT SNELLING
Practice Address - State:MN
Practice Address - Zip Code:55111-4080
Practice Address - Country:US
Practice Address - Phone:202-534-8226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6903103T00000X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist