Provider Demographics
NPI:1376038471
Name:ERTS, SEAN TYSON (RADT)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:TYSON
Last Name:ERTS
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 CAMINO DEL RIO S STE 129
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3544
Mailing Address - Country:US
Mailing Address - Phone:619-297-5131
Mailing Address - Fax:
Practice Address - Street 1:927 24TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2005
Practice Address - Country:US
Practice Address - Phone:619-233-8054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-30
Last Update Date:2018-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1293240318101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)