Healthcare Provider Details

I. General information

NPI: 1275932139
Provider Name (Legal Business Name): DR. SELENA MARIE JOHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2014
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 PENNSYLVANIA AVE
WAYNE PA
19087-3516
US

IV. Provider business mailing address

276 LINDENWOOD DR
EXTON PA
19341-2175
US

V. Phone/Fax

Practice location:
  • Phone: 610-687-2488
  • Fax:
Mailing address:
  • Phone: 215-378-8594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOC017462
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: