Provider Demographics
NPI:1275882383
Name:LANE SELMO, KERRY E (DPT)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:E
Last Name:LANE SELMO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30401 N 42ND PL
Mailing Address - Street 2:
Mailing Address - City:CAVE CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85331-3860
Mailing Address - Country:US
Mailing Address - Phone:480-292-6808
Mailing Address - Fax:
Practice Address - Street 1:3090 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4402
Practice Address - Country:US
Practice Address - Phone:602-745-2932
Practice Address - Fax:602-745-2963
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ116732251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ045576Medicaid