Provider Demographics
NPI:1497485783
Name:MOLINA, SELENE D (CMT)
Entity Type:Individual
Prefix:
First Name:SELENE
Middle Name:D
Last Name:MOLINA
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2390 LUCRETIA AVE APT 1906
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95122-4234
Mailing Address - Country:US
Mailing Address - Phone:956-789-7286
Mailing Address - Fax:
Practice Address - Street 1:5141 MOWRY AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1055
Practice Address - Country:US
Practice Address - Phone:956-789-7286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69096225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist