Basic Information
| Provider Information | |||||||||
| NPI: | 1922310655 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SELBO-BRUNS | ||||||||
| FirstName: | ALEXANDRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1217 E MAIN ST | ||||||||
| Address2: | #2B | ||||||||
| City: | SHRUB OAK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105881417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9147377338 | ||||||||
| FaxNumber: | 9147371050 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 MAIN ST | ||||||||
| Address2: | C/O WJCS | ||||||||
| City: | PEEKSKILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105662907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9147377337 | ||||||||
| FaxNumber: | 9147371050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2010 | ||||||||
| LastUpdateDate: | 07/03/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.