Provider Demographics
NPI:1053897371
Name:SELLERS, FLOYD HENRY
Entity type:Individual
Prefix:
First Name:FLOYD
Middle Name:HENRY
Last Name:SELLERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5336 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-1514
Mailing Address - Country:US
Mailing Address - Phone:619-462-8917
Mailing Address - Fax:619-462-8917
Practice Address - Street 1:10640 SCRIPPS RANCH BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1095
Practice Address - Country:US
Practice Address - Phone:760-529-6859
Practice Address - Fax:760-529-6859
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT21847106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQH14274726OtherPROVIEW SYSTEMS
CACAQH14274726Medicaid