Provider Demographics
NPI:1457479669
Name:SELVAGGI, DANIEL (LMT)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:SELVAGGI
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-1458
Mailing Address - Country:US
Mailing Address - Phone:812-339-1391
Mailing Address - Fax:
Practice Address - Street 1:205 N WALNUT ST
Practice Address - Street 2:SUITE 400
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3982
Practice Address - Country:US
Practice Address - Phone:812-340-5212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA9828225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist