Provider Demographics
NPI:1750686523
Name:SELLERS, MARY AMANDA WEILENMAN
Entity Type:Individual
Prefix:MRS
First Name:MARY AMANDA
Middle Name:WEILENMAN
Last Name:SELLERS
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 1:110 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-3733
Mailing Address - Country:US
Mailing Address - Phone:601-717-0910
Mailing Address - Fax:601-667-3203
Practice Address - Street 1:110 E CENTER ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-3733
Practice Address - Country:US
Practice Address - Phone:601-717-0910
Practice Address - Fax:601-667-3203
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3632225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist