Provider Demographics
NPI:1023431418
Name:SELMON, MAMIE
Entity type:Individual
Prefix:
First Name:MAMIE
Middle Name:
Last Name:SELMON
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 1:1019 BRASSIE AVE
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1352
Mailing Address - Country:US
Mailing Address - Phone:708-501-0861
Mailing Address - Fax:
Practice Address - Street 1:1019 BRASSIE AVE
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-1352
Practice Address - Country:US
Practice Address - Phone:708-501-0861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1062285222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist