Healthcare Provider Details

I. General information

NPI: 1366170805
Provider Name (Legal Business Name): SELENE QUETZAL LOPEZ PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 FIELDER NORTH PLZ
ARLINGTON TX
76012-2309
US

IV. Provider business mailing address

5040 VANDELIA ST
DALLAS TX
75235-8848
US

V. Phone/Fax

Practice location:
  • Phone: 817-461-4257
  • Fax: 817-461-4865
Mailing address:
  • Phone: 830-719-3594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1364803
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05015351A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: