Provider Demographics
NPI:1174148878
Name:SELLAM, SANDRA LEE (MS)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:SELLAM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10712 183RD STREET CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-8909
Mailing Address - Country:US
Mailing Address - Phone:206-639-3816
Mailing Address - Fax:
Practice Address - Street 1:10712 183RD STREET CT E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-8909
Practice Address - Country:US
Practice Address - Phone:206-639-3816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2023-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA103TF0200X
WAMC61062196101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic