Provider Demographics
NPI:1952644726
Name:TARDIF, SELINA (LMT)
Entity Type:Individual
Prefix:
First Name:SELINA
Middle Name:
Last Name:TARDIF
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 FORREST EDWARDS RD
Mailing Address - Street 2:
Mailing Address - City:OTISFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04270-6420
Mailing Address - Country:US
Mailing Address - Phone:207-212-4186
Mailing Address - Fax:
Practice Address - Street 1:99 FORREST EDWARDS RD
Practice Address - Street 2:
Practice Address - City:OTISFIELD
Practice Address - State:ME
Practice Address - Zip Code:04270-6420
Practice Address - Country:US
Practice Address - Phone:207-212-4186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-31
Last Update Date:2013-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT3658225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist