Healthcare Provider Details

I. General information

NPI: 1477078558
Provider Name (Legal Business Name): BROOKLYN MICHELLE SELLERS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2434 S EASON BLVD
TUPELO MS
38804-6942
US

IV. Provider business mailing address

152 HIGHWAY 7 S
OXFORD MS
38655-5392
US

V. Phone/Fax

Practice location:
  • Phone: 662-640-4595
  • Fax: 662-680-6416
Mailing address:
  • Phone: 662-234-7521
  • Fax: 662-236-3071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2555
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: