Provider Demographics
NPI:1205515111
Name:DAHLSTROM, SEAN O
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:O
Last Name:DAHLSTROM
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 1:102 1ST AVE W
Mailing Address - Street 2:
Mailing Address - City:SISSETON
Mailing Address - State:SD
Mailing Address - Zip Code:57262-1922
Mailing Address - Country:US
Mailing Address - Phone:970-506-4729
Mailing Address - Fax:
Practice Address - Street 1:9307 BRIDGEPORT WAY SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-1570
Practice Address - Country:US
Practice Address - Phone:253-201-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC61409258225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty