Healthcare Provider Details

I. General information

NPI: 1013723915
Provider Name (Legal Business Name): THERESA SELES HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 E 80TH AVE
MERRILLVILLE IN
46410-5737
US

IV. Provider business mailing address

1609 E 80TH AVE
MERRILLVILLE IN
46410-5737
US

V. Phone/Fax

Practice location:
  • Phone: 219-738-2730
  • Fax: 219-738-2743
Mailing address:
  • Phone: 219-738-2730
  • Fax: 219-738-2743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number17001655A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: