Provider Demographics
NPI:1700221330
Name:SELLHORN, BROOKE NICOLE (LMFT)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE
Last Name:SELLHORN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3717 OAKHURST DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-6238
Mailing Address - Country:US
Mailing Address - Phone:260-409-0609
Mailing Address - Fax:
Practice Address - Street 1:9417 SAINT JOE CENTER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-9259
Practice Address - Country:US
Practice Address - Phone:260-485-3692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001729A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1700221330Other01 - INDIVIDUAL