Provider Demographics
NPI:1750474284
Name:IVEY, SELENA PATRICE (RKT)
Entity type:Individual
Prefix:MRS
First Name:SELENA
Middle Name:PATRICE
Last Name:IVEY
Suffix:
Gender:F
Credentials:RKT
Other - Prefix:MS
Other - First Name:SELENA
Other - Middle Name:PATRICE
Other - Last Name:BURQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RKT
Mailing Address - Street 1:10346 1/2 RIVERSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602
Mailing Address - Country:US
Mailing Address - Phone:818-823-5227
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BOULEVARD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073
Practice Address - Country:US
Practice Address - Phone:310-478-3711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1687225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner