Provider Demographics
NPI:1417622929
Name:SELLMAN, CANDACE L
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:L
Last Name:SELLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1165
Mailing Address - Street 2:
Mailing Address - City:PHILIPSBURG
Mailing Address - State:MT
Mailing Address - Zip Code:59858-1165
Mailing Address - Country:US
Mailing Address - Phone:165-128-3289
Mailing Address - Fax:
Practice Address - Street 1:650 W SOUTH TEMPLE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84104-1007
Practice Address - Country:US
Practice Address - Phone:165-128-3289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT13815225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist