Provider Demographics
NPI:1376259721
Name:SELLERS, BROCK (LICSW, PIP)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:SELLERS
Suffix:
Gender:M
Credentials:LICSW, PIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5171 SAPPHIRE RDG
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-4172
Mailing Address - Country:US
Mailing Address - Phone:205-310-4827
Mailing Address - Fax:
Practice Address - Street 1:5330 STADIUM TRACE PKWY
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-4525
Practice Address - Country:US
Practice Address - Phone:205-490-6983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2292-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical