Provider Demographics
NPI:1518400043
Name:SELVAN, AMBIKA (PTA)
Entity Type:Individual
Prefix:
First Name:AMBIKA
Middle Name:
Last Name:SELVAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 WAKARUSA DR
Mailing Address - Street 2:SUITE E-1
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-4722
Mailing Address - Country:US
Mailing Address - Phone:785-856-7389
Mailing Address - Fax:785-856-7392
Practice Address - Street 1:1201 WAKARUSA DR
Practice Address - Street 2:SUITE E-1
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-4722
Practice Address - Country:US
Practice Address - Phone:785-856-7389
Practice Address - Fax:785-856-7392
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-02943225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS14-02943OtherKANSAS STATE BOARD OF HEALING ARTS