Healthcare Provider Details

I. General information

NPI: 1174148878
Provider Name (Legal Business Name): SANDRA LEE SELLAM MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2020
Last Update Date: 05/20/2023
Certification Date: 05/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10712 183RD STREET CT E
PUYALLUP WA
98374-8909
US

IV. Provider business mailing address

10712 183RD STREET CT E
PUYALLUP WA
98374-8909
US

V. Phone/Fax

Practice location:
  • Phone: 206-639-3816
  • Fax:
Mailing address:
  • Phone: 206-639-3816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC61062196
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: