Provider Demographics
NPI:1093254682
Name:WELLER, SEAN
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:WELLER
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 1:500 WILLOW AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-0827
Mailing Address - Country:US
Mailing Address - Phone:712-256-4420
Mailing Address - Fax:
Practice Address - Street 1:1720 N 16TH ST STE K
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-0109
Practice Address - Country:US
Practice Address - Phone:712-256-4420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-16
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA085718101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor