Healthcare Provider Details

I. General information

NPI: 1114986544
Provider Name (Legal Business Name): CAROLYN MARIE SELBY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22593 THREE NOTCH RD
CALIFORNIA MD
20619-3054
US

IV. Provider business mailing address

42001 PLEASANT VALLEY LN
HOLLYWOOD MD
20636-2311
US

V. Phone/Fax

Practice location:
  • Phone: 301-862-2505
  • Fax:
Mailing address:
  • Phone: 240-237-8619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number20403
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT16837
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: