Provider Demographics
NPI:1548425200
Name:SELBY, MELISSA BROOKS (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:BROOKS
Last Name:SELBY
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:PO BOX 412
Mailing Address - Street 2:2196 ASHLEY 69 ROAD HAMBURG
Mailing Address - City:PORTLAND
Mailing Address - State:AR
Mailing Address - Zip Code:71663-0412
Mailing Address - Country:US
Mailing Address - Phone:870-866-1029
Mailing Address - Fax:
Practice Address - Street 1:1402 C B KING RD
Practice Address - Street 2:
Practice Address - City:MC GEHEE
Practice Address - State:AR
Practice Address - Zip Code:71654-9403
Practice Address - Country:US
Practice Address - Phone:870-222-6211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA2056225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR165418721Medicaid