Provider Demographics
NPI:1629560602
Name:SELLERS, PATRICIA L
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:L
Last Name:SELLERS
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 1:16843 VALLEY BLOUVARD, SUITE E, # 526
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-6146
Mailing Address - Country:US
Mailing Address - Phone:626-201-8266
Mailing Address - Fax:
Practice Address - Street 1:220 S INDIAN HILL BOULEVARD, SUITE E
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711
Practice Address - Country:US
Practice Address - Phone:626-201-8266
Practice Address - Fax:909-971-3880
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA110530106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty