Provider Demographics
NPI:1366170805
Name:LOPEZ, SELENE QUETZAL (PT, DPT)
Entity type:Individual
Prefix:
First Name:SELENE
Middle Name:QUETZAL
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5040 VANDELIA ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-8848
Mailing Address - Country:US
Mailing Address - Phone:830-719-3594
Mailing Address - Fax:
Practice Address - Street 1:520 FIELDER NORTH PLZ
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-2309
Practice Address - Country:US
Practice Address - Phone:817-461-4257
Practice Address - Fax:817-461-4865
Is Sole Proprietor?:No
Enumeration Date:2022-08-11
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1364803225100000X
IN05015351A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist