Provider Demographics
NPI:1730654799
Name:SELLMAN, LEANNE MARIE
Entity Type:Individual
Prefix:
First Name:LEANNE
Middle Name:MARIE
Last Name:SELLMAN
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 1:3 ROXBURY CT
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-6151
Mailing Address - Country:US
Mailing Address - Phone:618-541-4575
Mailing Address - Fax:
Practice Address - Street 1:11960 WESTLINE INDUSTRIAL DR # 210
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3228
Practice Address - Country:US
Practice Address - Phone:314-574-5420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018034768225200000X
IL160008257225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant