Provider Demographics
NPI:1629407275
Name:SELBY, CHAD
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:SELBY
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 1:4049 MORRISON RD NW
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49676-9482
Mailing Address - Country:US
Mailing Address - Phone:906-250-8943
Mailing Address - Fax:
Practice Address - Street 1:2950 LAFRANIER RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-4918
Practice Address - Country:US
Practice Address - Phone:231-947-0506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201005086225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist