Provider Demographics
NPI:1952945073
Name:DILLON, SELAH (PTA)
Entity type:Individual
Prefix:
First Name:SELAH
Middle Name:
Last Name:DILLON
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 1:7310 N 16TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-5258
Mailing Address - Country:US
Mailing Address - Phone:602-535-8255
Mailing Address - Fax:
Practice Address - Street 1:7310 N 16TH ST STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-5258
Practice Address - Country:US
Practice Address - Phone:602-535-8255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ013350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist