Provider Demographics
NPI:1063538940
Name:SELBURG, JOAN K (CST)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:K
Last Name:SELBURG
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 NE GLEN OAK AVE
Mailing Address - Street 2:SUITE 407
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-4301
Mailing Address - Country:US
Mailing Address - Phone:309-672-5975
Mailing Address - Fax:309-655-1678
Practice Address - Street 1:120 NE GLEN OAK AVE
Practice Address - Street 2:SUITE 407
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-4301
Practice Address - Country:US
Practice Address - Phone:309-672-5975
Practice Address - Fax:309-655-1678
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL102326246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist