Provider Demographics
NPI:1003370370
Name:SEALY, SOPHIA
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:SEALY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1636 N CEDAR CREST BLVD # 148
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-2318
Mailing Address - Country:US
Mailing Address - Phone:929-292-0175
Mailing Address - Fax:
Practice Address - Street 1:527 HAMILTON ST STE 201
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18101-1511
Practice Address - Country:US
Practice Address - Phone:484-284-0342
Practice Address - Fax:484-212-9884
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC011113101YP2500X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA601365197Medicaid