Provider Demographics
NPI:1992850317
Name:RE, SEAN A (MFT)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:A
Last Name:RE
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 352
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-0352
Mailing Address - Country:US
Mailing Address - Phone:707-391-7326
Mailing Address - Fax:
Practice Address - Street 1:776 S STATE ST
Practice Address - Street 2:SUITE #107
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5847
Practice Address - Country:US
Practice Address - Phone:707-463-4915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 48843106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist