Provider Demographics
NPI:1689793606
Name:SELDERS, GINA GRAY (PTA)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:GRAY
Last Name:SELDERS
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 1:503 FREEMAN ST
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4192
Mailing Address - Country:US
Mailing Address - Phone:407-332-8297
Mailing Address - Fax:
Practice Address - Street 1:5433 W STATE ROAD 46
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-9236
Practice Address - Country:US
Practice Address - Phone:407-324-7204
Practice Address - Fax:407-324-7204
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA12587225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA12587OtherPHYSICAL THERAPIST ASSIST