Provider Demographics
NPI:1073042313
Name:SELBERT, GARY (LPC)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:SELBERT
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 SOUTHTOWNE
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-5729
Mailing Address - Country:US
Mailing Address - Phone:573-438-3733
Mailing Address - Fax:573-438-0046
Practice Address - Street 1:24 SOUTHTOWNE
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-5729
Practice Address - Country:US
Practice Address - Phone:573-438-3733
Practice Address - Fax:573-438-0046
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCS0001519101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional