Healthcare Provider Details

I. General information

NPI: 1124478714
Provider Name (Legal Business Name): NOELLE SELKOW PHD, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251C MCORMICK HALL CAMPUS BOX 5120
NORMAL IL
61790
US

IV. Provider business mailing address

101 AMBROSE WAY
NORMAL IL
61761-1821
US

V. Phone/Fax

Practice location:
  • Phone: 716-940-1212
  • Fax:
Mailing address:
  • Phone: 716-940-1212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.003259
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: