Provider Demographics
NPI:1447680293
Name:SELVY, THERESA (RD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:SELVY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8900 STERLING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97530-8933
Mailing Address - Country:US
Mailing Address - Phone:541-857-7130
Mailing Address - Fax:
Practice Address - Street 1:1200 MIRA MAR AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8546
Practice Address - Country:US
Practice Address - Phone:541-857-7130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR523133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered