Provider Demographics
NPI:1265571830
Name:SELBY, MARCIEL MARY (OTR)
Entity type:Individual
Prefix:
First Name:MARCIEL
Middle Name:MARY
Last Name:SELBY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:W7195 TERRITORIAL RD
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-2858
Mailing Address - Country:US
Mailing Address - Phone:262-495-2640
Mailing Address - Fax:
Practice Address - Street 1:W7195 TERRITORIAL RD
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-2858
Practice Address - Country:US
Practice Address - Phone:262-495-2640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225CA2400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorAssistive Technology Practitioner
Not Answered225CA2500XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorAssistive Technology Supplier
Not Answered225CX0006XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorOrientation and Mobility Training Provider
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40775300Medicaid