Provider Demographics
NPI:1275040859
Name:BROOKE SELLHORN LLC
Entity Type:Organization
Organization Name:BROOKE SELLHORN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:N
Authorized Official - Last Name:SELLHORN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:260-409-0609
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1700221330Other01 - INDIVIDUAL