Provider Demographics
NPI:1588175350
Name:SELLECK, MARIE ELIZABETH
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:ELIZABETH
Last Name:SELLECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:ELIZABETH
Other - Last Name:HUTCHINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 CHERRY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4526
Mailing Address - Country:US
Mailing Address - Phone:616-965-8200
Mailing Address - Fax:616-245-0450
Practice Address - Street 1:669 STOCKING AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-5176
Practice Address - Country:US
Practice Address - Phone:616-965-8200
Practice Address - Fax:616-940-5366
Is Sole Proprietor?:No
Enumeration Date:2017-10-19
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801100089104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker