Provider Demographics
NPI:1699146258
Name:GIBBONS, SELENA
Entity type:Individual
Prefix:MS
First Name:SELENA
Middle Name:
Last Name:GIBBONS
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 1:4069 BARNES AVE
Mailing Address - Street 2:LL
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-4328
Mailing Address - Country:US
Mailing Address - Phone:646-702-6965
Mailing Address - Fax:914-462-4513
Practice Address - Street 1:4069 BARNES AVE
Practice Address - Street 2:LL
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-4328
Practice Address - Country:US
Practice Address - Phone:646-702-6965
Practice Address - Fax:914-462-4513
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency