Provider Demographics
NPI:1891872362
Name:SELOCK, DANIEL ANDREW (MS/CADC/LCPC)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:ANDREW
Last Name:SELOCK
Suffix:
Gender:M
Credentials:MS/CADC/LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 SANDY PT
Mailing Address - Street 2:
Mailing Address - City:GOREVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62939-3122
Mailing Address - Country:US
Mailing Address - Phone:618-889-3987
Mailing Address - Fax:
Practice Address - Street 1:70 SANDY PT
Practice Address - Street 2:
Practice Address - City:GOREVILLE
Practice Address - State:IL
Practice Address - Zip Code:62939-3122
Practice Address - Country:US
Practice Address - Phone:618-889-3987
Practice Address - Fax:618-351-1419
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006639101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180006639OtherSTATE LICENSE, LCPC
IL03932079OtherBLUE CROSS BLUE SHIELD
IL11826508OtherCAQH