Provider Demographics
NPI:1730415944
Name:SELFRIDGE, CALLA L (PT, DPT, CMTPT)
Entity type:Individual
Prefix:
First Name:CALLA
Middle Name:L
Last Name:SELFRIDGE
Suffix:
Gender:F
Credentials:PT, DPT, CMTPT
Other - Prefix:
Other - First Name:CALLA
Other - Middle Name:L
Other - Last Name:DERUOSI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:PO BOX 69030
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-9030
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:204 GUMWOOD DR
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:VA
Practice Address - Zip Code:23430-6087
Practice Address - Country:US
Practice Address - Phone:757-357-7762
Practice Address - Fax:757-357-7765
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206270225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05954OtherGROUP MEDICARE PTAN
VAP00771554OtherRAILROAD MEDICARE
VA1730415944Medicaid
VA9304404OtherAETNA
VAP00771554OtherRAILROAD MEDICARE
VAC09457Medicare PIN