Provider Demographics
NPI:1700392941
Name:SELLECK, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SELLECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2768
Mailing Address - Street 2:
Mailing Address - City:CLEWISTON
Mailing Address - State:FL
Mailing Address - Zip Code:33440-6768
Mailing Address - Country:US
Mailing Address - Phone:561-707-5400
Mailing Address - Fax:
Practice Address - Street 1:7851 SE 95TH TRL
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34974-1317
Practice Address - Country:US
Practice Address - Phone:561-707-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-26
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty