=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760291983
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SELBY MEDICAL MASSAGE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2025
-----------------------------------------------------
Last Update Date | 01/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4111 E VALLEY AUTO DR STE 201
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85206-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-382-2537
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 952 S 96TH PL
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85208-3110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-315-7306
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MASSAGE THERAPIST
-----------------------------------------------------
Name | MRS. HEATHER SELBY
-----------------------------------------------------
Credential | LMT, CNMT, CMMP
-----------------------------------------------------
Telephone | 480-382-2537
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------