Provider Demographics
NPI:1801816111
Name:SEALY, ROGER C (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:C
Last Name:SEALY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 PAXON HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-1003
Mailing Address - Country:US
Mailing Address - Phone:610-353-3878
Mailing Address - Fax:610-353-4835
Practice Address - Street 1:890 PAXON HOLLOW RD
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-1003
Practice Address - Country:US
Practice Address - Phone:610-353-3878
Practice Address - Fax:610-353-4835
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005887L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0004541392OtherAETNA
PASE662223Medicare ID - Type Unspecified