Provider Demographics
NPI:1972336733
Name:PHAN, SELENA (DPT)
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15 LOUIS ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-5361
Mailing Address - Country:US
Mailing Address - Phone:516-697-0143
Mailing Address - Fax:
Practice Address - Street 1:475 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4819
Practice Address - Country:US
Practice Address - Phone:516-466-7723
Practice Address - Fax:516-466-7723
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY052960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist