Provider Demographics
NPI:1760177083
Name:SELCH, SALLY A
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:A
Last Name:SELCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:A
Other - Last Name:CLUTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:568 GITCHEGUMEE DR
Mailing Address - Street 2:
Mailing Address - City:BUCKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49620-9552
Mailing Address - Country:US
Mailing Address - Phone:269-274-7441
Mailing Address - Fax:
Practice Address - Street 1:1810 CHARTWELL DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49696-9283
Practice Address - Country:US
Practice Address - Phone:231-929-2354
Practice Address - Fax:231-929-2853
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician