Provider Demographics
NPI:1275277642
Name:WAIDO, SELENA
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:WAIDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MENDOTA
Mailing Address - State:IL
Mailing Address - Zip Code:61342-9216
Mailing Address - Country:US
Mailing Address - Phone:815-539-1409
Mailing Address - Fax:815-539-1652
Practice Address - Street 1:1401 E 12TH ST
Practice Address - Street 2:
Practice Address - City:MENDOTA
Practice Address - State:IL
Practice Address - Zip Code:61342-9216
Practice Address - Country:US
Practice Address - Phone:815-539-1409
Practice Address - Fax:815-539-1652
Is Sole Proprietor?:No
Enumeration Date:2022-04-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008276225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant