Healthcare Provider Details

I. General information

NPI: 1336867126
Provider Name (Legal Business Name): SELENA LAURIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2022
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 S LAKE AVE STE 300
PASADENA CA
91101-3009
US

IV. Provider business mailing address

1952 N BEACHWOOD DR APT 202
LOS ANGELES CA
90068-4007
US

V. Phone/Fax

Practice location:
  • Phone: 626-432-7270
  • Fax:
Mailing address:
  • Phone: 203-247-3695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-217208
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: