MEDICARE: MR. WALTER RAYMOND SELENS L.M.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MT1104	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	100191	OTHER	ME	ANTHEM BLUE CROSS

General Provider Information

NPI Number	:	1366579955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WALTER RAYMOND SELENS L.M.T.

Provider Business Mailing Address
First Line	:	500 FOREST AVE
Second Line	:	2ND FLOOR
City	:	PORTLAND
State	:	ME
Zip	:	04101
Country	:	US
Telephone Number	:	207-838-4394
Fax Number	:	207-878-3314

Provider Business Practice Location Address
First Line	:	500 FOREST AVE.
Second Line	:	2ND FLOOR
City	:	PORTLAND
State	:	ME
Zip	:	04101
Country	:	US
Telephone Number	:	207-838-4394
Fax Number	:	207-878-3314

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	07/24/2012

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Directions to “ MR. WALTER RAYMOND SELENS L.M.T.” Practice Location

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