Provider Demographics
NPI:1003395328
Name:SMITH, SEAN (AUD CCC-A)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:AUD CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 966
Mailing Address - Street 2:
Mailing Address - City:NOME
Mailing Address - State:AK
Mailing Address - Zip Code:99762-0966
Mailing Address - Country:US
Mailing Address - Phone:907-443-3311
Mailing Address - Fax:
Practice Address - Street 1:1000 GREG KRUSCHEK AVE
Practice Address - Street 2:
Practice Address - City:NOME
Practice Address - State:AK
Practice Address - Zip Code:99762-0966
Practice Address - Country:US
Practice Address - Phone:907-443-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK135954231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist