Healthcare Provider Details

I. General information

NPI: 1679379887
Provider Name (Legal Business Name): SELVYN SEWELL DR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2025
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 E HWY 50 STE A
CLERMONT FL
34711-5188
US

IV. Provider business mailing address

407 2ND ST
CLERMONT FL
34711-2301
US

V. Phone/Fax

Practice location:
  • Phone: 352-719-0930
  • Fax:
Mailing address:
  • Phone: 352-571-0274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11057
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: