Provider Demographics
NPI:1891460200
Name:WILSON, SEAN (LPT)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9160 HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-4894
Mailing Address - Country:US
Mailing Address - Phone:909-561-5215
Mailing Address - Fax:
Practice Address - Street 1:1160 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-5000
Practice Address - Country:US
Practice Address - Phone:626-335-5980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT41616167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician