Provider Demographics
NPI:1407121106
Name:SEAN'S PLACE, INCORPORATED
Entity Type:Organization
Organization Name:SEAN'S PLACE, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:541-995-5188
Mailing Address - Street 1:930 HAMMER ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97446-9590
Mailing Address - Country:US
Mailing Address - Phone:541-995-5188
Mailing Address - Fax:541-995-5061
Practice Address - Street 1:930 HAMMER ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:OR
Practice Address - Zip Code:97446-9590
Practice Address - Country:US
Practice Address - Phone:541-995-5188
Practice Address - Fax:541-995-5061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500620453Medicaid