1063621340 NPI number — SELMA SELENA GLADNEY MSOM, L.AC., LMT

Table of content: SUKESA MOORE (NPI 1750122792)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063621340 NPI number — SELMA SELENA GLADNEY MSOM, L.AC., LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLADNEY
Provider First Name:
SELMA
Provider Middle Name:
SELENA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSOM, L.AC., LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063621340
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1570 AVATI LN
Provider Second Line Business Mailing Address:
UNIT D
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60505-1647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-299-6754
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
932 N WRIGHT ST
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
NAPERVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60563-3600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-428-9001
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  227.005001 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171100000X , with the licence number: 198.000930 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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