Provider Demographics
NPI:1114399789
Name:SELAUSO, LECEL (PT)
Entity Type:Individual
Prefix:
First Name:LECEL
Middle Name:
Last Name:SELAUSO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23870 WATERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:NEW BOSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48164-7805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17197 N LAUREL PARK DR
Practice Address - Street 2:SUITE 555
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-2680
Practice Address - Country:US
Practice Address - Phone:734-779-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011424225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist