Provider Demographics
NPI:1477903540
Name:SELLERS, KOLTON WADE
Entity Type:Individual
Prefix:
First Name:KOLTON
Middle Name:WADE
Last Name:SELLERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 PLEASANT HILL RD
Mailing Address - Street 2:
Mailing Address - City:BONIFAY
Mailing Address - State:FL
Mailing Address - Zip Code:32425-8791
Mailing Address - Country:US
Mailing Address - Phone:850-849-1006
Mailing Address - Fax:
Practice Address - Street 1:4750 COLLEGIATE DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-1000
Practice Address - Country:US
Practice Address - Phone:850-770-2241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst