Provider Demographics
NPI:1831196245
Name:SELISCH, MAX OTTO (PT)
Entity type:Individual
Prefix:MR
First Name:MAX
Middle Name:OTTO
Last Name:SELISCH
Suffix:
Gender:M
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:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:PORT HADLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98339-0897
Mailing Address - Country:US
Mailing Address - Phone:360-385-9310
Mailing Address - Fax:360-379-8826
Practice Address - Street 1:27 COLWELL ST
Practice Address - Street 2:
Practice Address - City:PORT HADLOCK
Practice Address - State:WA
Practice Address - Zip Code:98339-0897
Practice Address - Country:US
Practice Address - Phone:360-385-9310
Practice Address - Fax:360-379-8826
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007845225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1831196245OtherNPI
WAG8929605Medicare PIN
1831196245OtherNPI