Healthcare Provider Details

I. General information

NPI: 1639036577
Provider Name (Legal Business Name): SELENA SOUTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2026
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4168 AVENIDA SEVILLA
CYPRESS CA
90630-3414
US

IV. Provider business mailing address

4168 AVENIDA SEVILLA
CYPRESS CA
90630-3414
US

V. Phone/Fax

Practice location:
  • Phone: 714-657-6577
  • Fax:
Mailing address:
  • Phone: 714-657-6577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number54430
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: