MEDICARE: SELINA LONG PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	06004696A	IN

General Provider Information

NPI Number	:	1205260312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SELINA LONG PTA

Provider Business Mailing Address
First Line	:	5152 TRUEMPER WAY
Second Line	:	APT 5
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-3268
Country	:	US
Telephone Number	:	574-265-3819
Fax Number	:

Provider Business Practice Location Address
First Line	:	5152 TRUEMPER WAY
Second Line	:	APT 5
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-3268
Country	:	US
Telephone Number	:	574-265-3819
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2013
Last Update Date	:	08/26/2013

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