Provider Demographics
NPI:1134503253
Name:SELLERS, TINA (LCSW)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:SELLERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 KAEN RD STE 367
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-4035
Mailing Address - Country:US
Mailing Address - Phone:503-742-5300
Mailing Address - Fax:503-742-5979
Practice Address - Street 1:998 LIBRARY CT STE 367
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-4041
Practice Address - Country:US
Practice Address - Phone:503-742-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-18
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW886521041C0700X
ORL83951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500774802Medicaid