Provider Demographics
NPI:1215065842
Name:SELEVAN, KATHLEEN BOYLE (RPT)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:BOYLE
Last Name:SELEVAN
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:MS
Other - First Name:KATHLEEN
Other - Middle Name:ANNE
Other - Last Name:BOYLE-SELEVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPT
Mailing Address - Street 1:1661 SUNSET RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-1241
Mailing Address - Country:US
Mailing Address - Phone:949-497-3111
Mailing Address - Fax:949-497-9510
Practice Address - Street 1:1661 SUNSET RIDGE DR
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-1241
Practice Address - Country:US
Practice Address - Phone:949-497-3111
Practice Address - Fax:949-497-9510
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10395225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT010395Medicare ID - Type Unspecified