Provider Demographics
NPI:1447837703
Name:SELBY, CINDY JO
Entity type:Individual
Prefix:
First Name:CINDY
Middle Name:JO
Last Name:SELBY
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 1:10494 W GLACIER PEAK DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99623-0796
Mailing Address - Country:US
Mailing Address - Phone:307-272-1130
Mailing Address - Fax:
Practice Address - Street 1:3543 E MERIDIAN PARK LOOP
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7233
Practice Address - Country:US
Practice Address - Phone:907-864-0099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
AKRBT-24-366475106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No175T00000XOther Service ProvidersPeer Specialist