Provider Demographics
NPI:1063088193
Name:BAREFOOT, SELENA RENEE
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:RENEE
Last Name:BAREFOOT
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 1:42 BARCLAY LN
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-7724
Mailing Address - Country:US
Mailing Address - Phone:703-479-4985
Mailing Address - Fax:
Practice Address - Street 1:14605 POTOMAC BRANCH DR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3336
Practice Address - Country:US
Practice Address - Phone:703-490-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-30
Last Update Date:2021-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306601791225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant