Provider Demographics
NPI:1073544011
Name:PAKDAMAN, SEAN (PHD QME)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:PAKDAMAN
Suffix:
Gender:M
Credentials:PHD QME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5535 BALBOA BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1516
Mailing Address - Country:US
Mailing Address - Phone:818-817-8737
Mailing Address - Fax:818-817-8738
Practice Address - Street 1:5535 BALBOA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1534
Practice Address - Country:US
Practice Address - Phone:818-817-8737
Practice Address - Fax:818-817-8738
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACP17001103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWCP17001AMedicare PIN