Healthcare Provider Details

I. General information

NPI: 1063088193
Provider Name (Legal Business Name): SELENA RENEE BAREFOOT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2021
Last Update Date: 05/30/2021
Certification Date: 05/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14605 POTOMAC BRANCH DR
WOODBRIDGE VA
22191-3336
US

IV. Provider business mailing address

42 BARCLAY LN
STAFFORD VA
22554-7724
US

V. Phone/Fax

Practice location:
  • Phone: 703-490-1112
  • Fax:
Mailing address:
  • Phone: 703-479-4985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306601791
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: