Provider Demographics
NPI:1750712584
Name:SELIS, MARK (BC-HIS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SELIS
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5042 OXFORD DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34242-1408
Mailing Address - Country:US
Mailing Address - Phone:941-320-2122
Mailing Address - Fax:
Practice Address - Street 1:2620 S TAMIAMI TRL
Practice Address - Street 2:SUITE 101
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-4517
Practice Address - Country:US
Practice Address - Phone:941-320-2122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-04
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS 962237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist