Basic Information
Provider Information | |||||||||
NPI: | 1689750721 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SELLERS | ||||||||
FirstName: | TARAH | ||||||||
MiddleName: | LEIGH | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC, NCC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GOODWIN | ||||||||
OtherFirstName: | TARAH | ||||||||
OtherMiddleName: | LEIGH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1041 W BRIDGE ST | ||||||||
Address2: | STE 1 | ||||||||
City: | PHOENIXVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 194604342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6109338110 | ||||||||
FaxNumber: | 6109337451 | ||||||||
Practice Location | |||||||||
Address1: | 1041 W BRIDGE ST | ||||||||
Address2: | SUITE 1 | ||||||||
City: | PHOENIXVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 194604342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6109338110 | ||||||||
FaxNumber: | 6109337451 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/31/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | PC003606 | PA | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.