Provider Demographics
NPI:1720385305
Name:BOBULA, SELENA A (DPT)
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:A
Last Name:BOBULA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 COCHRANE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913
Mailing Address - Country:US
Mailing Address - Phone:719-526-2361
Mailing Address - Fax:719-526-7732
Practice Address - Street 1:1650 COCHRANE CIRCLE
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913
Practice Address - Country:US
Practice Address - Phone:719-526-2361
Practice Address - Fax:719-526-7732
Is Sole Proprietor?:No
Enumeration Date:2011-02-17
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11608-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11608-24OtherSTATE LICENSE