Provider Demographics
NPI:1275089120
Name:SELBY, MICHELLE R (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:SELBY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27 WILSON RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04021-3120
Mailing Address - Country:US
Mailing Address - Phone:620-340-7888
Mailing Address - Fax:
Practice Address - Street 1:45 MALLETT DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-1312
Practice Address - Country:US
Practice Address - Phone:207-894-8104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME162861041C0700X
MELC162861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical