Provider Demographics
NPI:1154094878
Name:SELOF, GARY S
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:S
Last Name:SELOF
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 1:1401 WESTSIDE DR
Mailing Address - Street 2:
Mailing Address - City:POLK CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50226-1014
Mailing Address - Country:US
Mailing Address - Phone:515-971-3792
Mailing Address - Fax:
Practice Address - Street 1:1850 SW PLAZA SHOPS LN STE D
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-7168
Practice Address - Country:US
Practice Address - Phone:515-508-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000417101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health