Provider Demographics
NPI:1558651786
Name:SELLE, VIRGINIA (PHD, LCPC, NCC, LMT)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:SELLE
Suffix:
Gender:F
Credentials:PHD, LCPC, NCC, LMT
Other - Prefix:
Other - First Name:GINNI
Other - Middle Name:
Other - Last Name:SELLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, LCPC, NCC, LMT
Mailing Address - Street 1:515 E OAK AVE
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3854
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 E OAK AVE
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3854
Practice Address - Country:US
Practice Address - Phone:630-730-1871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-08
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005722101YP2500X
IL227000480225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist