Healthcare Provider Details

I. General information

NPI: 1215435813
Provider Name (Legal Business Name): ALICIA SELVIG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 01/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 FOX CHASE DR
HATTIESBURG MS
39402-2575
US

IV. Provider business mailing address

711 AVIGNON DR
RIDGELAND MS
39157-5120
US

V. Phone/Fax

Practice location:
  • Phone: 601-264-8828
  • Fax:
Mailing address:
  • Phone: 601-605-6777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5278
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: