Provider Demographics
NPI:1205270071
Name:SELBY, SUSAN M (GC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:SELBY
Suffix:
Gender:F
Credentials:GC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:CORDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 INDUSTRIAL RD STE 410
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-2396
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 INDUSTRIAL RD STE 410
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-2396
Practice Address - Country:US
Practice Address - Phone:650-249-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-24
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN740000054A170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300008082Medicaid