Healthcare Provider Details

I. General information

NPI: 1275277642
Provider Name (Legal Business Name): SELENA WAIDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 04/22/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 E 12TH ST
MENDOTA IL
61342-9216
US

IV. Provider business mailing address

1401 E 12TH ST
MENDOTA IL
61342-9216
US

V. Phone/Fax

Practice location:
  • Phone: 815-539-1409
  • Fax: 815-539-1652
Mailing address:
  • Phone: 815-539-1409
  • Fax: 815-539-1652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.008276
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: