Provider Demographics
NPI:1467491753
Name:SELMER, LISA D (PT, MPT, CWS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:SELMER
Suffix:
Gender:F
Credentials:PT, MPT, CWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 E STONER AVE
Mailing Address - Street 2:PM&RS (117)
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4243
Mailing Address - Country:US
Mailing Address - Phone:318-424-6014
Mailing Address - Fax:318-429-5727
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:PM&RS (117)
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-424-6014
Practice Address - Fax:318-429-5727
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04138225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist