Provider Demographics
NPI:1770100927
Name:LOVE, SELENA MICHELLE
Entity type:Individual
Prefix:MISS
First Name:SELENA
Middle Name:MICHELLE
Last Name:LOVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12501 CHANDLER BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-1955
Mailing Address - Country:US
Mailing Address - Phone:818-821-6012
Mailing Address - Fax:818-821-6014
Practice Address - Street 1:644 E REGENT ST STE 105
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1443
Practice Address - Country:US
Practice Address - Phone:818-821-6012
Practice Address - Fax:818-821-6014
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program