Healthcare Provider Details

I. General information

NPI: 1063621340
Provider Name (Legal Business Name): SELMA SELENA GLADNEY MSOM, L.AC., LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 03/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

932 N WRIGHT ST SUITE 120
NAPERVILLE IL
60563-3600
US

IV. Provider business mailing address

1570 AVATI LN UNIT D
AURORA IL
60505-1647
US

V. Phone/Fax

Practice location:
  • Phone: 630-428-9001
  • Fax:
Mailing address:
  • Phone: 630-299-6754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198.000930
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.005001
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: