Healthcare Provider Details

I. General information

NPI: 1669007779
Provider Name (Legal Business Name): SELENA WATCHMAN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2020
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3530 PAN AMERICAN FWY NE STE D
ALBUQUERQUE NM
87107-4793
US

IV. Provider business mailing address

419 BRISTLEBRUSH ST SW
ALBUQUERQUE NM
87121-2514
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-4469
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5617
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: