Provider Demographics
NPI:1598969156
Name:MCCORKLE, SELENA CHRISTIE (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:SELENA
Middle Name:CHRISTIE
Last Name:MCCORKLE
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:SELENA
Other - Middle Name:ANN
Other - Last Name:CHRISTIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2001 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7126
Practice Address - Country:US
Practice Address - Phone:540-387-4120
Practice Address - Fax:540-387-4121
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306601280225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant