Provider Demographics
NPI:1669789624
Name:SELLE, LYNN MARIE (PT)
Entity type:Individual
Prefix:MS
First Name:LYNN
Middle Name:MARIE
Last Name:SELLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CHARLEVOIX DR SE STE 200
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7086
Mailing Address - Country:US
Mailing Address - Phone:800-684-8048
Mailing Address - Fax:
Practice Address - Street 1:750 E LOUISIANA ST
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-9501
Practice Address - Country:US
Practice Address - Phone:715-483-9815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1584-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist